Early Follow-Up Is Key to Patient Success in Collaborative Care

Collaborative care is a proven approach to integrate and improve mental health care in the primary care setting, leading to better outcomes for patients and potential long-term health care cost savings.

However, most studies of the collaborative care model have focused on the model as a whole package, leaving some unanswered questions about the relative importance of the different components of the model for patient outcomes.

In a study published November 16 in Psychiatric Services in Advance, Yuhua Bao, Ph.D., of the departments of Psychiatry and Healthcare Policy and Research at Weill Cornell Medical College and colleagues evaluated the impact of two collaborative care processes on outcomes in patients with depression: a care manager’s follow-up with a patient within four weeks of the initial visit (whether by person or by phone) and a psychiatric consultation within four weeks if a patient does not improve after the first eight weeks of treatment.

“We picked these particular tasks because they embody key principles of the collaborative care model, they take place during the first weeks when care management is most critical, and they apply to every patient,” Bao said.

Bao and her colleagues studied Washington’s Mental Health Integration Program (MHIP), a publicly funded collaborative care model that includes more than 100 community health centers from across the state. They examined the records of 5,439 adult psychiatric patients with severe depression (defined as a PHQ-9 score of greater than or equal to 10) who had initiated care in MHIP clinics in King and Pierce counties, the two most populous counties in Washington state and where this program first started.

In this population, having a follow-up visit in the first four weeks was associated with speedier recovery, with those patients achieving their first clinically meaningful improvement in their depression scores (that is, PHQ-9 dropped below 10) about twice as fast as patients who did not receive a follow-up. Overall, 42.8 percent of patients with at least one follow-up contact in the first four weeks achieved clinically significant improvement in 24 weeks compared with 34.4 percent among those who had no follow-up within four weeks.

Providing a psychiatric consultation to patients who did not improve after eight weeks also increased the odds of recovery after 24 weeks (25 percent achieved improvement compared with 20 percent of patients without a consultation), though consultation was not associated with any faster rate of recovery.

“These findings reinforce how critical the first few weeks of treatment are for patients who come into a care setting with acute depression,” Bao said. “Not only will a follow-up provide important information about the patient’s response to treatment, but it also strengthens the bond with the caregivers, which can help patients stay compliant.”

Bao noted that this study does not imply that other process-of-care elements of a collaborative care model are trivial, and she believes that additional studies should examine other key tasks to gain a more comprehensive picture of collaborative care model processes from start to finish.

Bao is unsure, however, whether strengthening these two processes outside of a collaborative care setting would show improvements. “These key processes are often practiced together, and they enable and reinforce each other. They should be seen as part of a holistic package, and not items on a menu that practices can pick and choose.”

This study was funded by grants from the National Institute of Mental Health. ■