Can Collaborative Care Really Help Patients With Depression and Diabetes or Heart Disease?

General Hospital Psychiatry recently published four articles that detail the results of COMPASS, a large-scale multisite collaborative care model for patients with depression and diabetes and/or cardiovascular disease. This month’s authors describe the study’s results and encourage us to learn the skills needed to work in collaborative care settings. —Jürgen Unützer, M.D., M.P.H.

The first patient you see today is a 60-year-old man who lost his ability to cope when his back “gave out” in 2005. He presents with symptoms of depression and a PHQ-9 score of 20. He lost his job and cannot afford either his medication or his housing costs. In addition, his type 2 diabetes is out of control with an HgA1c of 10.7, his hypertension is poorly controlled, and he has a history of MI with a stent. His psychiatric, medical, and social problems require more help than any one health professional can individually provide.

Patients with complex interconnected problems are common and can be frustrating as they frequently do not improve. Is the situation hopeless? A 2010 randomized trial of TEAMcare found that collaborative care is substantially better than usual care for these complex patients. Sadly, six years later this intervention has not been widely adopted in medical practice, a common occurrence for effective but complex medical interventions, especially when both medical and psychiatric problems need to be addressed.

The leap from a randomized effectiveness trial to widespread implementation can be bridged with dissemination initiatives that engage diverse real-world clinics to work together to implement key changes while encouraging local adaptations. The Center for Medicare and Medicaid Innovation created Health Care Innovation Challenge Awards to encourage health care systems to undertake such initiatives. They awarded the Institute of Clinical Systems Improvement $18 million for COMPASS (Care of Mental, Physical and Substance use Syndrome), with the goal of implementing and sustaining a modified version of TEAMcare in 172 clinics from 18 medical groups in eight states. Evaluation support was provided by HealthPartners Institute, and the project tracking system was supported by the AIMS Center (Advancing Integrated Mental Health Solutions).

COMPASS was completed in 2015 and described recently in detail in four articles in General Hospital Psychiatry. The first article, “The COMPASS Initiative: Description of a Nationwide Collaborative Approach to the Care of Patients With Depression and Diabetes and/or Cardiovascular Disease,” describes the COMPASS intervention, goals, and collaborative sites. It emphasizes the importance of an expanded care team, including a nurse care manager and both psychiatry and medical consultants who together performed weekly systematic case reviews of all patients who were not improving. The team created individualized care plans for new patients and recommended treatment changes to primary care clinicians for patients with PHQ-9 scores greater than or equal to 10, HgA1c greater than or equal to 8, high LDL, or hypertension. The article concludes that “a diverse set of health care systems and other organizations can work together to rapidly implement an evidence-based care model for complex, hard-to-reach patients.”

The second article, “Impact of a National Collaborative Care Initiative for Patients With Depression and Diabetes or Cardiovascular Disease,” reports on the clinical outcomes and satisfaction results from over 3,600 patients and over 680 clinicians. Of those patients with uncontrolled disease at enrollment, 40 percent achieved depression remission or response, 23 percent controlled their blood glucose, and 58 percent controlled their blood pressure. Patients and clinicians reported satisfaction with COMPASS care.

The third article, “Understanding the Experience of Care Managers and Relationship With Patient Outcomes: the COMPASS initiative,” describes the experiences of this new role for care managers and reports that care managers who had more contacts with patients had better patient outcomes. Since many patients had complex nonmedical needs, care managers identified a need for involvement of medical social workers as well.

The fourth article, “Clinician Burnout and Satisfaction With Resources in Caring for Complex Patients,” reports on a survey of 709 of the COMPASS clinicians and finds that 31 percent were experiencing burnout before COMPASS started. This seemed to be associated with having “lower satisfaction with resources to treat complex patients,” thereby suggesting the need for the kinds of resources COMPASS provided.

A substantial barrier to the implementation of collaborative care programs in the United States has been a lack of provider reimbursement. In a major breakthrough, the Centers for Medicare and Medicaid Services (CMS) has proposed new billing codes for collaborative care that would “establish separate payment for collaborative care, particularly how we might better value and pay for robust interprofessional consultation, between primary care physicians and psychiatrists (developing codes to describe and provide payment for the evidence-based psychiatric collaborative care model …).”

How can psychiatrists learn the skills needed to work in collaborative care settings? In 2015, CMS awarded APA a Transforming Clinical Practice Initiative Support and Alignment Network grant to train 3,500 psychiatrists to work in the collaborative care model. You can sign up to participate in free online modules and to see where in-person programs are being planned.

Later this year, APA will begin training primary care physicians through online and in-person trainings. Additionally, training in multi-condition collaborative care is offered by the AIMS Center. For more information on APA trainings, email [email protected].

Collaborative care can make an important difference for our 60-year-old patient above and others with comorbid physical and mental health conditions. Consider engaging in this care model to help improve both patient outcomes and patient and clinician satisfaction with care. ■