As the director of the AIMS Center, I have had the privilege of helping hundreds of clinics implement collaborative care, an integrated model of mental health care developed at the University of Washington. It is satisfying to know that our work has helped improve care for tens of thousands of patients. But we have also learned that implementing practice change is challenging, and not all efforts succeed.
We recently worked with staff of a busy Federally Qualified Health Center (FQHC) as part of a three-year initiative to bring collaborative care to their clinic and to other clinics in their state. For the first two years, the clinic was a model of implementation of collaborative care, with high provider satisfaction and strong clinical outcomes, despite a challenging patient population, but by the third year, its successes were rapidly unraveling, and eventually collaborative care was completely abandoned.
Major drivers of this unraveling included the turnover of key leaders, losing both experienced care managers within six months of each other, hiring of a care manager who was not a good fit for the position, and lack of planning for long-term financial viability of the program at the end of grant funding. Most importantly, the organization never fully integrated the program into its overall mission, vision, and clinical operations. As a stand-alone behavioral health program, it fell apart when its champions left the organization. This was particularly heartbreaking given the previous strength of the program and its exemplary clinical outcomes. The areas with which this FQHC struggled are not uncommon and are worth a closer look.
Shared vision: Creating a vision for how collaborative care is part of the mission and essential services of an organization is critically important. This vision should include the core components of collaborative care, including a commitment to tracking a defined population of patients and a commitment to “treatment to target,” making sure that patients’ treatments are actively changed until clinical goals are achieved. Without a vision that ties collaborative care to the mission of the organization, several staff members who opposed collaborative care, including the financial director and the new care manager, were able to derail the program. Clinical outcomes went from exemplary to no better than typical usual care within a few short months.
Leadership: Within a very short time, the FQHC experienced organizational leadership changes (CEO, CMO), lost its psychiatric consultant due to retirement, and lost two talented care managers who had initiated the collaborative care program. This resulted in a lack of continuity and posed a significant challenge. Strong leadership that embraces a shared vision of collaborative care and values it as a way of providing evidence-based care for patients is critical in order to weather staffing turnover and loss of institutional knowledge. Without it, a loss of one or two champions can put an entire program at risk.
Staffing: The FQHC’s new care manager was not a good fit. She did not feel comfortable with evidence-based treatments designed for primary care settings, struggled with using a registry to drive a population-based treatment-to-target approach, focused on more traditional counseling, and did not value care management components of collaborative care that are important in producing better outcomes. It became increasingly clear she was more comfortable with a traditional co-located behavioral health model instead of true “collaboration” with the clinic’s primary care providers, and she became increasingly used for crisis intervention, not necessarily for patients needing depression treatment. She was not willing to learn a different way of practicing, which is so important in the role of an effective primary care–based care manager. Hiring staff who understand and embrace collaborative care is crucial to the success of evidence-based integrated care programs.
Financial sustainability plan: During the first year of implementation, the organization’s CMO questioned whether the program was “another grant-funded effort doomed to go away when the money goes away,” and no serious efforts were made to develop a financial sustainability plan. Had collaborative care been a more integral part of the FQHC’s organizational vision, greater attention might have been given to generating revenue and making collaborative care financially stable.
Case studies like this one can help providers and organizations avoid mistakes made by others and pave the way to more successful implementations. Our team now spends more time working with organizational leadership upfront to help them create a shared vision for collaborative care as part of their mission and essential services.
It is important to remember that putting effective integrated care into place is not easy. It requires practice change on multiple levels, and it is nothing short of a new way of delivering care. Every team member is challenged to learn new skills and more importantly, to work together somewhat differently from the traditional way of doing his or her job. This can feel disruptive at times, but the evidence from more than 80 randomized, controlled studies is clear that effectively implemented collaborative care not only improves patient and provider satisfaction with care, but it also improves patient outcomes and can even reduce overall health care costs.
As integral members of collaborative care teams, psychiatrists have a unique and important role in helping shape an organization’s vision and in helping support and sustain it through the challenges that inevitably surface as the organization transforms itself into an effective integrated care program. ■