Reflections on Implementation of Collaborative Care

It’s been a pleasure for me to watch the growth and development of our new Integrated Care Fellowship housed at the University of Washington and funded by the Washington state legislature. Our first fellows, the authors of this month’s column, have done an excellent job leading, nurturing, and educating integrated care teams to effectively deliver collaborative care in both urban and rural settings. By providing integrated care training to early career psychiatrists, we hope to prepare a growing workforce equipped to improve access to effective behavioral health care. —Jürgen Unützer, M.D., M.P.H.

As the first fellows of the new Integrated Care Fellowship offered by the Department of Psychiatry and Behavioral Sciences at the University of Washington, we had the privilege of helping shape the program from the ground up. The unique fellowship, directed by Anna Ratzliff, M.D., Ph.D., focuses on developing both clinical and leadership skills to deliver population mental health with an emphasis on how to leverage psychiatric expertise through working with other providers.

As part of the fellowship, we both participated in a year-long “Implementation Rotation” in which we helped a primary care clinic within Washington state start a collaborative care program. This was a terrific, hands-on opportunity that gave us enormous insight into the complexities of launching an integrated care program and the components that are necessary for success. Below are some highlights from our experience:

Implementation #1, Seeta Patel, M.D.

My implementation site, a primary care clinic located in rural Washington, consisted of four family medicine providers and two on-site behavioral health specialists who provided psychotherapy. Quality improvement was already part of the organizational culture, and due to a shortage of psychiatric providers in the clinic’s rural location, there was a drive to shift from co-located psychotherapy to collaborative care.

We formed a stakeholder team that included an implementation expert, two psychiatric consultants (an attending and me as the fellow), two care managers, a care manager supervisor, a PCP “champion,” the clinic manager, and organizational leaders including the chief medical officer. Our stakeholder team developed a shared vision for the program, an essential foundation moving forward. We also outlined our workflow and created a post-launch communication plan to evaluate the program’s efficacy.

Team members demonstrated remarkable enthusiasm and perseverance throughout the implementation. In particular, the care managers’ dedication to the shared integrated care vision led them to advocate for changes to achieve that vision. The care managers were also integral in creating an effective workflow to effectively communicate recommendations to PCPs, despite the presence of separate electronic medical records for primary care and behavioral health.

Additional post-launch site visits will further lay the foundation and address any questions regarding workflow early on in the development process. In addition, monthly calls between the psychiatric consultant and the PCPs for “Lunch and Learn” sessions will provide an opportunity to discuss patients with complex care needs and to review brief didactic presentations on how to manage common mental health conditions.

Implementation #2, Sara Haack, M.D., M.P.H.

My implementation site, an internal medicine clinic located in a medium-sized Washington town, recognized that its Medicare-heavy patient population had few community options for psychiatric care. As the Medicare population frequently has multiple medical comorbidities, the clinic prioritized improving population’s mental health to facilitate better overall health outcomes.

Establishing institutional and ground-level support for the program was our critical first step. Leadership demonstrated commitment by allocating funds and clinical space to support a new care manager. A PCP “champion” generated enthusiasm for collaborative care among his colleagues, while the clinic’s prior experience with a chronic care manager made the new collaborative care model feel more familiar. The collaborative care team’s program coordinator had previously worked in the chronic care model as well. Her familiarity with a team-based, outcomes-driven care model was an asset to the team throughout the process.

Similar to Dr. Patel’s experience, our implementation was successful because of the individuals involved. One blessing in disguise was that the newly hired care manager was unable to see patients during his first month on the job while being credentialed. He capitalized on this prolonged orientation period by diligently studying his collaborative care responsibilities and making a consistent effort to visit with the clinic providers. Before even seeing patients, the PCPs trusted him to deliver effective care, which was extremely important as referrals steadily arrived once the program opened.

There are many opportunities to define and measure our program’s outcomes, with an eye to “scaling up” the collaborative care program to other areas and patients within the clinic and to other clinics within the same health care system.

Take-Away Points From Rotation

• The PCP champion is essential to the implementation process. Checking in with the PCP champion regularly allowed us to continually reflect on opportunities for improvement.

• Laying the foundation for collaborative care and delineating clear roles for all team members are important first steps for implementation.

• Having a strong care manager is invaluable, as this is the person who liaises most with patients and with all other collaborative care team members.

• Anecdotal success stories from patients and providers are heartening to the rollout of a new collaborative care program. Identifying metrics of success and reviewing progress toward these metrics are key parts of the model’s accountable care principle.

These themes are beneficial to any clinic thinking about starting a collaborative care program, and we will draw upon them and our implementation experience as we continue our careers in delivering population-based mental health. ■