Anticipation Said Key to Success of Collaborative Chronic MH Care

Getting ahead of a patient’s mental health and illness may be one key to good medical care, said Mark Bauer, M.D., at APA’s Institute on Psychiatric Services in New York in October.

Ellen Dallager

The approach has, of course, proven effective for other chronic illnesses.

“The collaborative chronic care model has worked in diabetes, asthma, arthritis, congestive heart failure, and depression treated in primary care,” said Bauer, a professor of psychiatry at Harvard Medical School and associate director of the VA Center for Organization, Leadership, and Management Research in Boston.

Originally proposed by Edward Wagner, Brian Austin, and Michael Von Korff in an article in the Milbank Quarterly in 1996, the goal of collaborative chronic care is to provide “evidenced-based, anticipatory, continuous, collaborative care,” said Bauer.

The central word in that list is “anticipatory,” he said.

“Historically, patients have come into our offices with a problem; we fix it, and they come back the next time with a new problem,” he said. “Anticipatory care identifies what is likely to go wrong with the patient and minimizes potential problems while maintaining close contact with the patient and other involved providers.”

But achieving collaborative, preventive, continuous care that will improve outcomes takes more than a phrase. Bauer listed several essential areas for change.

Practices must be redefined, he said. “Work roles may change, and so may scheduling practices, follow-up, and outreach for missed appointments.”

Patients will also need support for enhanced self-management that goes beyond education about their illness.

For this model to succeed, clinicians require access to expert consultation, whether in person or online. Interactive information-management techniques must get the right information into prescribers’ hands at the right time—like having lithium levels available before the scheduled appointment time rather than after.

Finally, the patient must be linked to community resources, including peer support.

Bauer presented results of a study that included a meta-analysis and a systematic review of clinical trials testing the model.

The meta-analysis of 57 clinical trials showed significant effects for collaborative-care models across disorders and care settings for depression and for mental and physical quality of life, Bauer said.

“A broad, diverse set of trials favored collaborative chronic care models,” he said. “There were smaller effect sizes in mixed, messy, real-world populations but they were still clinically significant.”

Costs in this model of collaborative chronic care were not different compared with those for controls.

The next step in using the collaborative chronic care model is learning how to enhance clinic-based care to get greater treatment effects while moving beyond the clinic walls.

For the latter, adoption could be hampered by practice size, said Bauer.

“Most primary behavioral health care practices in the U.S. are too small to adopt the model,” he said. “We may have to think about linking clinics together in groups,” possibly in cooperation with state-sponsored and commercial insurance plans.

“Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty, and Behavioral Health Care Settings: Systematic Review and Meta-Analysis” is posted at http://ajp.psychiatryonline.org/article.aspx?articleid=1213771.