Abstract and Keywords
The past two decades have witnessed a surge in the growth of initiatives and funding to weave physical and behavioral health care, particularly with identification of the high costs incurred by their comorbidity. In response, a robust body of evidence now demonstrates the effectiveness of what is referred to as collaborative care. A wide range of models transverse the developmental lifespan, diagnostic categories, plus practice settings (e.g., primary care, specialty medical care, community-based health centers, clinics, and schools). This article will discuss the foundational elements of collaborative care, including the broad sweep of associated definitions and related concepts. Contemporary models will be reviewed along with identified contextual topics for practice. Special focus will be placed on the diverse implications collaborative care poses for the health and behavioral health workforce, especially social workers.
Collaborative care is an evidence-based approach that involves the provision of mental health, behavioral health, and substance use services within a primary care setting (Fortney et al., 2015; Unützer, Harbin, Schoenbaum, & Druss, 2013). For the purposes of this article, primary care is defined as health care provided by a medical professional (as a general practitioner, pediatrician, nurse) with whom the patient has initial contact and by whom the patient may be referred to a specialist (Merriam-Webster, 2015). Of the 40% of people with a mental health or substance use disorder who receive treatment, 23% are treated by a primary care provider or other general medical provider (Fortney et al., 2015).
Primary care settings have long served as the gateway for many individuals who experience behavioral health issues, along with presenting health-care needs (SAMHSA-HRSA Center for Integrated Health Solutions, 2015a). However, the complex comorbidity experienced by this patient population contributes to care that is often viewed as substandard. Comorbidity is defined as the co-occurrence of mental and physical disorders in the same person, regardless of the chronological order in which they occurred or the causal pathway linking them (Robert Wood Johnson Foundation, 2011).
Three factors contribute to the less-than-optimal quality of care for this population. Studies show primary care physicians (PCPs) around the globe unprepared to coordinate care for patients with complex chronic conditions. In the United States, 24% of PCPs were unprepared to coordinated care for these patients, with 84% unprepared to manage patients with severe mental health diagnoses alone. Of PCPs in Germany and the Netherlands who felt prepared to care for patients with severe mental health issues, the number sits at 12% (Osborn, Moulds, Schneider, Doty, Squires, & Sarnak, 2015).
The second factor involves the current time constraints in place for office visits. The average wait time experienced by patients to see their PCP is 19.5 days across metropolitan areas, with the average visit a duration of 11 to 15 minutes (Mazzolini, 2014; Rabin, 2014). The limited patient visit time negates the importance of the patient-provider relationship by allowing for less dialogue, thus a missed opportunity to engage patients in care (Rabin, 2014). Frustration expressed by the patient does not enhance this dimension of the care process. In the end, only 13% of individuals diagnosed with a mental health disorder receive appropriate treatment in primary care, while for substance use that number drops to 5% (Fortney et al., 2015).
The mental health workforce shortage serves as the final factor impacting the quality of care for those individuals with comorbid chronic illnesses, especially behavioral health concerns. More than half of the counties in the United States do not have a single practicing mental health professional (Fortney et al., 2015). Exactly 3,968 whole or partial counties have been identified as “Health Professional Shortage Areas” for mental health. These areas are defined as those where there is less than one psychiatrist per 30,000 people. It is estimated that 2,707 more clinicians in those areas are warranted to assure appropriate intervention for the population (Robeznieks, 2015). This problem is particularly acute in rural areas of the country. There are widespread shortages of psychiatrists from both a maldistribution (e.g., inner city and suburban regions as opposed to rural communities) and the aging out of professionals, which contribute to rampant problems with access to appropriate care and delays in treatment (Fortney et al., 2015; Robeznieks, 2015; Russell, 2010). Nearly half of the world’s population lives in a country where there is less than one psychiatrist per 100,000 people (Robeznieks, 2015).
The failure to recognize and appropriately treat behavioral health conditions has a significant impact on health outcomes and costs (Fortney et al., 2015; Klein & Hostetter, 2014). Those patients with mental health diagnoses use more medical resources, are more likely to be hospitalized for medical conditions, and are readmitted to the hospital more frequently (Klein & Hostetter, 2014). Collaborative care provides a means to proactively manage mental disorders as chronic diseases rather than treating acute symptoms (Eghaneyan, Sanchez, & Mitschke, 2014).
A number of terms are used to represent collaborative care across the literature. They include, but are not limited to, integrated care, coordinated care, behavioral health integration, and shared care. Collaborative care is under the larger umbrella title of integrated care (Fortney et al., 2015). Viewed as a more complete and comprehensive process of care delivery, integrated care provides a global overview of the full treatment process. It is described as bringing together inputs, delivery, management, and organization of services as a means of improving access, quality, user satisfaction and efficiency (Gröne & Garcia-Barbero, 2002). Often aligned with systems theory, original dialogues on integrated care combined theory and practice as a means to reduce the existing gaps between medical diagnosis and social problems (2002). The latter are also referred to as the social determinants of illness and have a profound impact on health, wellness, and prevention. They include the economic and social conditions that influence group differences in health status. (Health Affairs, 2014; Schumann, 2015).
A lens that encompasses mental health, substance abuse, and primary care services ultimately produces more successful outcomes for patients. This collective perspective is proven the most effective approach to caring for people with multiple health-care needs (Fortney et al., 2015; SAMHSA-HRSA, 2015b; Unützer et al., 2013; Robert Wood Johnson Foundation, 2011).
The Chronic Care Model
Collaborative care approaches share a heritage with the chronic care model (CCM). Emerging at the end of the 20th century, CCM was developed to help primary care practices improve patient health outcomes by altering the routine delivery of ambulatory care (Coleman, Austin, Brach, & Wagner, 2009). The CCM premise accepts how true improvement in care delivery requires an approach to involve the patient and provider, along with system level interventions. There is acknowledgement of the vital importance for professionals to consider the macro and mezzo influences with potential to impact their micro interventions with patients. Among these macro/mezzo influences are the societal challenges of socioeconomic status including poverty, housing stability, lack of employment, insurance reimbursement, and other social determinants impacting the incidence and prevalence of both mental disorders and medical conditions (Robert Wood Johnson Foundation, 2011).
A powerful element of CCM draws on the synergy of engaging multidisciplinary teams in the treatment process. Distinct perspectives and expertise of involved professionals provide the opportunity for the teams to create a partnership with the patient. The team concept has advanced considerably from the traditional medical model of practice; one that yielded a hierarchical structure and top-down style where physicians are presented as more important than patients and family members within the health-care partnership (Zimmerman & Dabelko, 2007). The integration of multidisciplinary teams has been viewed as an efficient means to improve overall illness management (Flandt, 2006, Interprofessional Education Collaborative, 2011; Robert Wood Johnson Foundation, 2011).
The CCM strived to transform the daily care for patients with chronic illnesses from acute and reactive processes to those which are proactive, planned, and population-based actions. Six concepts ground the model including:
1. Organizational support
2. Clinical information systems
3. Delivery system design
4. Decision support
5. Self-management support, and
6. Community resources
The scope of each domain is shown in Figure 1.
The general features of collaborative care models are
• integration of mental health professionals in primary care medical settings
• close collaboration between mental health and medical/nursing providers
• shared responsibility in the planning, delivery, and evaluation of health services
• focus on treating the whole person and whole family.
Five core principles define collaborative care and are acknowledged by the industry as mandatory for the effective implementation of any related program. These include:
1. patient-centered team care
2. population-based care
3. measurement-based treatment to target
4. evidence-based care
5. accountable care
(Advancing Integrated Mental Health Solutions, 2015b)
Table 1 provides a detailing of each core principle. All are consistent with the industry mandates for team-focused care, which are actively being implemented across practice settings (Advancing Integrated Mental Health Solutions, 2015c; Fortney et al., 2015; Interprofessional Education Collaborative, 2011).
1. Patient-centered Team Care
Primary care providers, care managers, and behavioral health consultants collaborate effectively using shared care plans that incorporate patient goals.
2. Population-based Care
Care team shared a defined group of patients tracked in a registry to ensure no one falls through the cracks.
Practices track and reach out to patients who are not improving and mental health specialists provide caseload-focused consultation as opposed to ad-hoc advice.
3. Measurement-based Treatment to Target
Each patient’s treatment plan clearly articulates personal goals and clinical outcomes that are routinely measured by evidence-based tools (e.g., PHQ-9 Depression Scale). Treatments are actively changed if patient are not improving as expected until clinical goals are achieved.
4. Evidence-based Care
Patients are offered treatments with credible research evidence to support their efficacy in treatment of the target condition. These include various evidence-based psychotherapies proven to work in primary care (e.g., Problem Solving Treatment, Cognitive Behavioral Therapy) and medications.
5. Accountable Care
Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided.
The dedicated team members include the primary care provider, care/case managers, and psychiatric consultants and/or behavioral health specialists (Unützer et al., 2013). In the traditional primary care setting, the treatment team has two members: the primary care provider and the patient. Collaborative care adds a minimum of two essential roles: a behavioral health professional who functions as a care or case manager (typically embedded in the program) and a psychiatric consultant (typically engaged by phone or tele-video link). This comprehensive multidisciplinary approach serves as a preemptive method to screen and track mental conditions in primary care settings. The team approach is both clinically and cost effective in treating patients with comorbid conditions (Eghaneyan et al., 2014; Fortney et al., 2015; Robert Wood Johnson Foundation, 2011; Unützer et al., 2013).
Evidence and Industry Alignment
Original empirical evidence for collaborative care lent itself to treating depression and anxiety (Archer et al., 2012; Fortney et al., 2015; Klein & Hostetter, 2014). The 2012 Cochrane review of 79 research trials documented how the model significantly improved depression and anxiety outcomes for 24,308 participants, compared with standard primary care (Fortney et al., 2015; Archer et al., 2012). The presence of depressive symptoms in patients increased their risk of thirty day hospital readmission by nearly 40% (Epstein Becker Green, 2015). Health-care costs for Medicaid beneficiaries diagnosed with major depression and a chronic medical condition are twice as high as those for beneficiaries without depression (Unützer et al., 2013).
The challenge of medical and mental health comorbidity has been a motivator for acceptance and implementation of collaborative care. Sixty-eight percent of adults with mental disorders have medical conditions, while 29% of adults with medical conditions have mental disorders. Thirty-five percent of patients with a chronic illness have a mental illness (Epstein Becker Green, 2015) so that comorbidity poses a huge challenge for health-care stakeholders, patients, and providers alike. Unmanaged patients with mental illnesses cost insurance payers more than double to manage chronic conditions (Epstein Becker Green, 2015). The core reason for this challenge involves a “mismatch between the clinical reality in which medical conditions and mental health conditions are overlapping and interrelated, and a health care system in which the providers, clinics and treatments are separated” (Robert Wood Johnson Foundation, 2011, p. 15) Fragmented, rather than cohesive care has been the norm.
Patients with mental and substance use disorders are less likely than individuals in the general population to receive routine preventive services such as immunizations, cancer screenings, and smoking cessation counseling. The common signs of depression and anxiety are frequently lost amid somatic complaints (e.g., headaches, fatigue, stomach pain). Veterans who experience Post-Traumatic Stress Disorder (PTSD) have higher rates of physical symptoms compared to veterans without PTSD. Yet, an injured veteran will more often have the emphasis of care on physical rehabilitation, with little to no attention to prevailing behavioral symptoms or any signs of emotional distress. (Robert Wood Johnson Foundation, 2011; Grieger et al., 2006).
Adults with severe mental illness (SMI) do not receive care reflective of their overall health and behavioral health needs. They die 25 years earlier on average than most of the population. This dynamic is often attributed to disproportionately high rates of mortality from the same preventable conditions that are the leading causes of death in the general population, including cardiovascular and pulmonary disease (Nardone et al., 2014). The end result is a reactive approach to care that can stress an already burdened health-care system in most instances. Examples include missed suicide warnings, clogged emergency rooms, high hospital readmission rates, plus structural and financial strains on the health care system as a whole (Fortney et al., 2015).
In addition, co-occuring substance-use disorders are prevalent among those persons diagnosed with SMI. Yet, treatment for mental health and substance abuse systems have remained entirely separate from the physical health system. This level of disintegration contributes to inappropriate, if not disjointed, care gaps in terms of intervention and redundant care and can result in increased health-care costs (Nardone et al., 2014).
The expansion of collaborative care has been associated with another imperative shared by mental health and primary care, the Triple Aim of health-care reform. Through its efficient approach to addressing a patient’s co-occurring manifestations of clinical psychopathology amid pathophysiology, collaborative care achieves the Triple Aim by lowering costs while improving clinical outcomes and patient satisfaction (Fortney et al. 2015; Institute for Healthcare Improvement, 2015). These three items are interdependent and viewed as the integral means by which the U.S. health-care system will be improved. It is paramount for emphasis to be placed by the industry on improving the experience of care for all involved stakeholders, improving the health of populations, and reducing the per capita costs of health care (Berwick, Nolan, & Whittingham, 2008).
Emerging research for collaborative care finds increasing applications for other conditions. These include PTSD and comorbid medical conditions such as heart disease, diabetes, and cancer. Additional research speaks to the improvement of patient functioning at home and at work, reduction in disability, plus improving clinical outcomes, increasing patient satisfaction, and quality of life (Fortney et al., 2015)
Profound shifts in care delivery and payment models, along with an industry focus on patient-centered care, have driven a societal mandate to implement collaborative care approaches. Key drivers for collaborative care include:
• passage of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 and the Patient Protection and Affordable Care Act (ACA) of 2010
• costs of care, and
• payment and reimbursement
Each of these concepts and their distinct influence on the collaborative care movement will be explored in the following section.
Mental Health Parity and Addiction Equity Act (MHPAEA)
The MHPAEA, passed in 2008 requires:
group health plans and health insurance issuers to ensure that financial requirements (e.g., co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits … MHPAEA supplements prior provisions under the Mental Health Parity Act of 1996 (MHPA), which required parity with respect to aggregate lifetime and annual dollar limits for mental health benefits.
(United States Department of Labor, 2015)
In addition, MHPAEA applied to plans sponsored by private and public sector employers with more than fifty employees, including self-insured and fully insured arrangements, as well as health insurance issuers who sell coverage to employers with more than 50 employees (United States Department of Labor, 2015).
Collaborative care is viewed as an underlying tenet of health reform. It was expected that the enactment of MHPAEA (along with the ACA) would serve as an opportunity for the health-care industry to implement strategies that would integrate mental health care within primary care, particularly with parity guaranteed under the law. Use of the CCM (as previously discussed) was expected to further support this effort (Goodrich, Kilbourne, Nord, & Bauer, 2013). However, despite passage of laws to support it, full parity between health and mental health has evolved slowly. There is wide discrepancy across the states in terms of implementation, scope of care, and treatment limitations. (Kennedy Forum, 2015a).
A number of legal cases have been and continue to be litigated at both the state and federal levels (Kennedy Forum, 2015a, 2015b). An executive order from the White House in 2014 announced nineteen executive actions to improve mental health for service members, veterans, and their families (WhiteHouse.gov., 2014). A further mandate by the president in early 2015 to enforce mental health parity implementation across the states brought heightened awareness to the issue, though inconsistent advancement of the concept (WhiteHouse.gov., 2014). The federal agencies responsible for enforcing MHPAEA have tried to facilitate action as well. The Department of Labor (DOL), the Department of Health and Human Services (HHS), and the Department of the Treasury (DoT) issued a final rule on the federal law in November of 2013. The Centers for Medicaid and Medicare Services (CMS) issued a proposed rule regarding Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (benchmark and benchmark equivalent plans), and the Children’s Health Insurance Program (CHIP) (Kennedy Forum, 2015b).
Patient Protection and Affordable Care Act (ACA)
As discussed in the prior section, the ACA intended to extend mental health and substance use disorder benefits and parity protections to all Americans. Through protections under the law, insurers would be prohibited from denying coverage because of preexisting conditions for a diagnosis of mental illness and require most insurance plans to cover recommended preventive services without copays, including behavioral assessments for children and depression screenings. While full mental health parity is still an elusive goal under the ACA, several of the law’s programs and initiatives that rely on the concept of collaborative care have been successful in moving forward.
First, the ACA extended the concept of parity to specifically include mental health and substance-use disorder services as one of the 10 required essential health benefits (Nardone et al., 2014). Table 2 provides the full listing of benefit categories. While discretion has been left to individual states and their insurance plans to define the exact benefits for each category, the overall categories themselves remain constant.
Table 2. Affordable Care Act’s Essential Ten Health Benefits (Data adapted from Healthcare.gov., 2013).
1. Outpatient care
Includes the kind of care rendered without a person being admitted to a hospital.
2. Emergency room visits
3. Treatment in the hospital for inpatient care
4. Care before and after a baby is born
5. Mental health and substance use disorders services
Includes behavioral health treatment, counseling, and psychotherapy.
6. Prescription drugs
7. Services and devices to help a patient recover if injured, or have a disability or chronic condition.
Includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
8. Lab tests
9. Preventive services
Includes counseling, screenings, and vaccines to keep persons healthy and care for managing a chronic disease.
10. Pediatric services
Includes dental care and vision care for children and adolescents.
Second, new mechanisms and funding opportunities have been designed to promote coordinated and patient, or person-centered, care. Person-centered care promotes the concept that the care provided is respectful of and responsive to individual patient preferences, needs, and values, and ensures that patient values guide all clinical decisions (Institute of Medicine, 2001). The process is marked by transparency, individualization, recognition, respect, dignity, and choice in all matters related to one’s personal circumstances and relationships in health care (Berwick, 2009). Both patient and family are expected to be actively engaged at every level of care design and implementation.
A prime example of the patient centered care focus forged by the ACA, is the Medicaid option for health homes. These programs strive to improve both outcomes and functioning, plus reduce health-care costs for targeted beneficiaries with chronic conditions. While authorized by federal law, individual states have discretion in that each one has the option to link Medicaid beneficiaries who have at least two chronic conditions, have one chronic condition and are at risk for another, or have a serious mental illness to a health home. The chronic conditions listed in the ACA Statute, Section 2703 are:
• mental health
• substance abuse
• heart disease
• being overweight
• additional consideration for other chronic conditions, such as HIV/AIDS
Through the oversight provided, the person’s health care can be coordinated in a way that accounts for treating the whole person. Associated providers must meet existing federal and state qualification to serve as health homes and deliver services within the program parameters. These involve integrating all primary, acute, behavioral health, long-term services, and support that are warranted by the person. The ultimate outcome of the home health model is improved integration of primary and behavioral health-care delivery (Medicaid.gov., 2016 Unützer et al., 2013).
Health homes must provide the following services:
• comprehensive care management
• care coordination and health promotion
• transitional inpatient to outpatient care
• individual and family support
• referrals to community and social support services
• services linked through health information technology
Third under the ACA is the development of Accountable Care Organizations (ACOs). ACOs are defined as a group of doctors, hospitals, and other health-care providers who come together voluntarily to give coordinated, high-quality care to their Medicare patients. The goal of this coordinated care is to ensure that patients, especially those with chronic illnesses, receive the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When the ACO is successful in delivering high-quality care and spending health-care dollars more wisely, it will share in the savings it achieves for the Medicare program (CMS.gov., 2015). However, while most ACOs hold responsibility for behavioral health costs, few have included models that integrate care for mental illness and substance use with primary care (Lewis et al., 2014). The three original types of ACOs are shown in Table 3, along with the Next Generation ACO Model scheduled to begin in 2017.
Medicare Shared Savings Program
A program that helps a Medicare fee-for-service program providers become an ACO.
Advance Payment ACO Model
A supplementary incentive program for selected participants in the Shared Savings Program.
Pioneer ACO Model
A Program designed for early adopters of coordinated care. It is no longer accepting applications.
*Next Generation ACO Model
A program offering a new opportunity in accountable care—one that sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.
The goal of the model is to test whether strong financial incentives for ACOs, coupled with tools to support better patient engagement and care management, can improve health outcomes and lower expenditures for the original Medicare fee-for-service beneficiaries.
Collaborative care provides a comprehensive approach for those who live with chronic comorbid conditions. Technology has greatly altered the health and behavioral health landscape, allowing vast numbers of involved providers to communicate and intervene more efficiently and effectively with patients and their family systems. The two constructs of collaborative care and technology forge a powerful dyad to advance the quality of treatment rendered to complex, chronically ill patients who require constant attention to health and behavioral health issues.
The stigma often experienced by patients with mental health concerns can be minimized through access to intervention afforded via the latest generation of telehealth products. Individuals who reside in rural or underserved regions can be engaged in a process by logging on to a computer with a webcam and Internet connection. Individuals with acute psychopathology, which limits their ability to seek and obtain care, are able to get intervention without leaving home. Delays in care and high costs are incurred when patients with medical and behavioral health symptoms must wait in the emergency department for necessary psychiatric clearance. These situations are known to clog up emergency departments, hampering their ability to provide the necessary assessment and treatment. Technology serves to accelerate care by providing virtual psychiatry consults that facilitate patient assessment and identification of necessary intervention, which is an effort deemed better for both patient and organization (Hunt, Vyas, Chu, Lee, & Creado, 2015; Gupta, 2015).
Collaboration among providers is critical in the health-care industry. However, nowhere is this more apparent than in behavioral health issues (e.g., mental health and substance use disorders). The high costs of poor collaboration for this population appear throughout the literature (Epstein Becker Green, 2015; Fortney et al., 2015; Milliman, Inc., 2014; Robert Wood Johnson Foundation, 2011). Electronic health records (EHRs) and related clinical information systems now provide expedited and immediate access for practitioners to view the clinical status of patients, including current documentation. They offer readily available, comprehensive information about the patient to those who deliver, manage, and receive care (Marchibroda, 2008). The industry continues to weigh in on the promises and pitfalls of EHRs, although adoption rates for primary care are at 86% (Epstein Becker Green, 2015) However, while professionals report challenges with how EHRs may interfere with the time spent interfacing with patients (Friedberg, Crosson, & Tutty, 2014), others tout the value they bring to the care process. In addition, they offer patients greater engagement in their care, as well as the opportunity to possess greater understanding of their condition and treatment plan.
The shift toward value-based care translates to a mandate for health-care stakeholders to collaborate. Technology products from telehealth solutions, mobile apps to EHRs, and other technologies are making a higher level of collaboration possible (Gupta, 2015). They make a major difference in the efforts of the health-care team to effectively manage chronic care. Technology reduces, if not eliminates, many of the barriers to effective chronic care management by providing important clinical information about the patient when it is needed, and where it is needed, in a timely, secure fashion (Marchibroda, 2008). On the whole, technology provides greater access to health-care services, thus empowering clients who previously faced barriers to preventive care (Reardon, 2011).
Collaborative care is viewed as a worthwhile strategy to meet organizational goals, which are increasingly focused on quality and cost of patient care. Poor care coordination has a price tag averaging from $25 billion to $45 billion dollars annually (Epstein Becker Green, 2015). Patients who have a co-occuring behavioral health condition receive intervention from the health-care system significantly more frequently, with their bills 50%–175% higher than similarly ill patients without a behavioral health condition (Gupta, 2015; Milliman, Inc., 2014).
Behavioral health conditions are extremely common, affecting one in five Americans and leading to health-care costs of $57 billion dollars annually (Klein & Hostetter, 2014). Globally the numbers are even more staggering. The World Economic Forum identified mental disorders as having among the largest cost drivers at $2.5 trillion dollars with projected costs of $6.0 trillion dollars by the year 2030; greater than the costs of diabetes, respiratory disorders, and cancer combined (Insel, 2015).
Mental illness is twice as prevalent for Medicaid beneficiaries; 49% of whom with disabilities are also diagnosed with a psychiatric illness (Kronick, Bella, & Gilmer, 2009). Behavioral health comorbidities have a profound impact on overall cost of health care. The costs for beneficiaries who have three or more chronic conditions increases significantly, from 66% to 75% of total spending for those with disabilities. The average total monthly expenditure for a person with a chronic disease and depression is $560 dollars more than for a person without depression; the discrepancy for people with and without comorbid anxiety is $710 (Robert Wood Johnson Foundation, 2011).
From the perspective of employers, collaborative care models are a logical mode of care delivery when reviewing costs. Depressive disorders contribute to more sick days annually than any other condition. An analysis of health claims and disability data from employees of a large corporation showed that persons with comorbid mental and medical conditions cost employers approximately twice as much as those with either condition alone (Druss et al., 2000). Insurers pay significantly more to manage the costs incurred by patients who have comorbid diagnoses, as high as 276% (Epstein Becker Green, 2015).
Collaboration among providers is critical across the entire continuum of health care. Across the top nine chronic conditions, depression and anxiety go undiagnosed 85% of the time (Epstein Becker Green, 2015). Mental health and substance use issues are an increasing part of the overall clinical picture, with patients put at greater risk when they are not addressed appropriately by providers due to lack of communication. Outcomes note a prevalence of high financial costs resulting from poor professional collaboration alone. (Cohen et al., 2015; Letourneau, 2015; Milliman, Inc., 2014; Robert Wood Johnson Foundation, 2011).
Payment and Reimbursement
Restrictive payment methods and practice patterns have impeded full collaboration across disease states (Klein & Hostetter, 2014). While the ACA has promoted enhanced mechanisms and funding for reimbursement of collaborative care, expansion across the care continuum has been slower than expected. Challenges are presented as collaborative care models require funding the salary of additional and/or dedicated team members (e.g., care managers, diabetes educators, behavioral health professionals). In addition, the long-term patterns of delivering care and the requisite payment structures, including fees for service payment models, are not easily abandoned (Caffrey, 2015).
New value-based care models serve as incentive to implement collaborative care. Outcomes demonstrate improved medical and behavioral health adherence to treatment, with improvement in overall functioning across populations (Engel, 2014; Fortney et al., 2015; McGregor, Lin, & Katon, 2011; Robert Wood Johnson Foundation, 2011). The care coordination fee, passed by the Center for Medicare and Medicaid Services (CMS), is seen as another positive step. As of January 2015, physicians or staff incident to physicians can earn a chronic care management fee of $42.60 per eligible patient per month under specific conditions, which include:
• The PCP must perform (and bill separately for) an initial preventive physical, followed by an annual wellness exam.
• Each eligible patient must have a written care plan, with twenty minutes spent each month on care coordination for that patient by a licensed care team member.
• The patient must have 24/7 access for urgent care needs, including telephone consultation, and the team is responsible for hospital post-discharge and ED follow-up.
• The PCP must maintain all EHR activity.
• The physician must get the patient’s written consent to act as care coordinator, because the service is subject to a Medicare deductible. It is acknowledged that some patients who most need coordination may refuse to do this.
Suggestions for reimbursement include instituting monthly case rates, capitation, episode of care payments and pay for performance initiatives that support effective integrated care. Care management and psychiatric case review and/or consultations can be covered through bundled payment or fee for service arrangements. As the cost structures continue to get tighter, old models of reimbursement where behavioral health patients are outsourced elsewhere, will no longer be effective, funded, or financially successful (Letourneau, 2015).
Collaborative Care Program Examples
Collaborative Care models are appearing across the industry and expanding rapidly, with many active demonstration projects. This section will present a brief overview of several successful models.
Care of Mental, Physical and Substance Use Syndromes (COMPASS). Identified as one of the largest collaborative care implementation initiatives, COMPASS involved over 4,000 Medicare and Medicaid patients across 187 clinics across seven states: California, Colorado, Massachusetts, Michigan, Minnesota, Pennsylvania, and Washington (Fortney et al., 2015). A core Systematic Case Review (SCR) team intervened with chronically ill patients with uncontrolled depression and uncontrolled diabetes and/or heart disease. The following components were included:
1. An initial evaluation to measure condition severity and assess the patient’s readiness for self- management
2. A computerized registry to track and monitor the patient’s progress
3. A care manager to provide patient education and self-management support, coordinate care with the primary care physician and consultants, and provide active follow-up
4. A consulting psychiatrist and consulting medical physician to review cases with the care manager and recommend changes in treatment to the primary care physician
5. Treatment intensification when there is a lack of improvement
6. Relapse and exacerbation prevention
Overall aggregated results from all eighteen participating regional groups demonstrated goals exceeded for depression, heart disease, and diabetes improvement (Advancing Integrated Mental Health Solutions, 2015e; Fortney et al., 2015).
Improving Mood-Promoting Access to Collaborative Treatment (IMPACT). One of the largest collaborative care trials to date is the IMACT study. It tested the model on 1,801 depressed older adults treated over two years in eighteen primary-care clinics across five states: Washington, California, Texas, Indiana, and North Carolina. The population mix included health maintenance organizations (HMOs), traditional fee for service clinics, one independent provider association (IPA), an inner-city public health clinic, and two Veteran’s Administration (VA) clinics (Fortney et al., 2015; Advancing Integrated Mental Health Solutions (AIMS) Center, 2015d).
During the study, half the patients were randomly assigned to receive their normal primary care, including medications and/or referral to mental health. The other half were randomly assigned to the IMPACT model, receiving a collaborative approach. At the end of twelve months, half of the patients receiving collaborative care reported at least a 50% reduction in depressive symptoms, compared with only 19% of those in usual care (Advancing Integrated Mental Health Solutions (AIMS) Center, 2015d). IMPACT patients also experienced more than 100 additional depression-free days over a two-year period than those treated in the traditional primary-care model. There were significant reductions identified in long-term overall health-care costs. The overall return on investment (ROI) was found to be $6 saved for each dollar spent on depression care (Fortney et al., 2015).
RESPECT-Mil and Stepped Enhancement of PTSD Service Using Primary Care: STEPS-UP. The RESPECT-Mil is an evidence-based systems approach to providing PTSD and depression care to soldiers in a primary care setting. The RESPECT-Mil treatment model involves primary care providers, assisted by RESPECT-Mil Care Facilitators (RCFs) trained to screen their patients for depression and PTSD, then communicate with them about behavioral health issues. Program advantages included:
• identifying and treating problems early;
• delivering effective, easy-to access care in the primary care setting with reduced stigma and promoting collaboration between primary care and behavioral health in military treatment facilities;
• improved continuity of care for problems that require long-term, sustained interventions, so soldiers are less likely to “fall through the cracks” of the complex health services delivery system;
• use of a web-based care management tool to track treatment effects in real time.
By the end of 2013, RESPECT-Mil was running in 88 clinics and had improved care for tens of thousands of military personnel in more than 3 million patient visits. A five-year randomized effectiveness trial of a second-generation approach to RESPECT-Mil was later implemented; STEPS-UP: (Stepped Enhancement of PTSD Services Using Primary Care). STEPS-UP served as the first randomized effectiveness trial of behavioral and mental health piloted with the U.S. Military Health System as a whole. Conducted at six installations (eighteen clinics), STEPS-UP was available to 1,041 military members over twelve months. It added several additional components including:
• centralized implementation assistance;
• stepped psychotherapies making use of Internet and telephone;
• care manager training in intensive patient-engagement strategies for greater continuity; and
• routine use of automated registries to identify patients in need of treatment changes.
The TEAMcare Study. The TEAMcare intervention was conducted in Group Health (GH) Cooperative, a large HMO in Washington State. For 12 months, a patient-centered intervention was integrated for 240 patients across primary care. It was acknowledged on the front end of the study how patients with poorly controlled diabetes, coronary heart disease, and depression have an increased risk of adverse outcomes. The goal of was to improve disease control for medical and psychological illnesses manifesting for patients with comorbid diagnoses of major depression and diabetes. Several patients with additional psychiatric diagnoses were excluded (e.g., bipolar disorder, schizophrenia, or dementia). Most patients involved in the study were treated at the same GH primary care clinic for years, and were well known to their primary care teams (McGregor et al., 2011).
The TEAMcare intervention team consisted of the patients, designated nurse case managers, the patient’s primary care physician (PCP) and that PCP’s care team, plus a number of TEAMcare consultants including two psychiatrists, an internist, a family medicine physician, and one psychologist. Other specialty consultations (e.g., cardiologists, diabetologist) were involved as necessary. At the end of the 12 months, changes were noticed with respect to both behavioral and medical adherence (McGregor et al., 2011)
Professional Implications and Conclusion
Career Impact for Social Work. Health-care reform has brought considerable new career opportunities for social workers by fueling the expansion of delivery models to integrate behavioral health within primary care. The Bureau of Labor Statistics forecasts a 12% increase in jobs for social workers alone, faster than the average for all occupations (Bureau of Labor Statistics, 2016). Those who have practiced within (especially) the medical social work realm are well positioned to assume leadership roles as hospitals make the shift to more patient-centered care (Zimmerman & Dabelko, 2007). The expertise of social workers and other behavioral health professionals translates to them becoming more prevalent in primary care settings (Reardon, 2011).
Collaborative care models more fully address the biopsychosocial needs of individuals and families in primary care. Ongoing demographic shifts (e.g., older adults living longer with chronic conditions) speak to an expanding complexity of psychosocial problems faced by patients who enter primary care (Keefe, Geron, & Enguidanos, 2009). Social workers are uniquely trained to engage, assess, intervene, and evaluate practice with respect to these biopsychosocial needs for diverse individuals, families, groups, organizations, and communities. The competencies that set the foundation for baccalaureate and master’s social work education (and thus practice) are implicit to this end (Council on Social Work Education, 2015).
The emphasis on self-determination as a cornerstone value of social work equally highlights the contribution the profession can make to care coordination. This is especially important as new models of care, particularly ones that rely on the premise of patient-centered care, further expand, including Medicaid Health Homes and ACOs (Fink-Samnick, 2011). Social workers are poised to play a major role in collaborative care through direct application of their distinct competencies, knowledge, values, skills, and expertise.
Barriers to Implementation. Industry experts (Epstein Becker Green, 2015; Fortney et al., 2015; Klein & Hostetter, 2014) identify several barriers to total implementation of collaborative care, including:
1. continued societal stigma surrounding mental illness;
2. lack of attainment for full mental health parity, with inconsistent legislation across the states;
3. absence of a payment structure that supports evidence-based integrated care practices for treating mental health and substance use disorders in primary care;
4. lack of a large enough mental health workforce skilled in supporting primary care providers;
5. ongoing lack of support by some primary care practices to implement collaborative care approaches;
6. lack of industry consensus on comprehending the impact of the Health Information Portability and Accountability Act (HIPAA) and its scope with respect to privacy and confidentiality of mental health records, plus the sharing of information across collaborative care provider networks.
Case Management Certification:
Further information on the Collaborative Care model, IMPACT and other demonstration projects.
Reports and current news on funding and related topics specific to promotion of high performing health systems for society’s most vulnerable populations, including Collaborative and Integrated care models.
Function as an innovator, convener, partner, and driver of results in health and health-care improvement worldwide.
Current reports on achieving health quality in collaborative and integrated care models.
Reports, demonstration projects, and funding to promote interprofessional education and team models across the health care industry.
Mental Health Parity Tracker: Shows current legislation federally and at the state level.
Issue Brief: Fixing Behavioral Health Care in America-provides a detailing of current collaborative care demonstration projects in the United States.
Resources and reports on the current status of mental health parity in the United States.
Issue briefs, reports, and resources on Collaborative and Integrated Care.
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