How to Implement Effective Integrated Care

It has been 15 years since the publication of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, which established an effective approach for treating older adults with depression in primary care settings. Since that 2002 publication, this model of care has demonstrated effectiveness for a variety of behavioral health diagnoses including anxiety disorders, attention-deficit disorder, substance use disorders, posttraumatic stress disorder, dementia, and others, with new research on the model being published on a steady basis.

The basic design of the IMPACT model has successfully demonstrated good outcomes from pediatric to geriatric populations, in urban and rural settings, for patients from different racial groups and socioeconomic backgrounds, and across different clinic and payer types. A robust return on investment, due to decreased overall medical spending, is in line with the Triple Aim of health care reform.

Despite this success, the consistency of outcomes at the individual clinic level has been variable, with outcomes, even in the clinical trials, demonstrating some clinics do strikingly better—or worse—than others. Poor outcomes can impede both the accountability for the care provided as well as dampen enthusiasm for the model. With so much evidence behind the collaborative care model (CoCM), one could ask “How could it fail?” without understanding what leads to an unsuccessful implementation. At a time when value-based payment is becoming more widely expected, it is imperative to use what we have learned from past experience to our advantage, so new projects can be successful from the start. Moreover, with the approval of new CPT codes for collaborative care, clinics will want to quickly prepare for their use, and guidance must be available to ensure successful implementation.

The inconsistency in outcomes is caused by a variety of factors, including adherence to the core principles on which collaborative care is based; key tasks connected to these principles that must be performed; and key features of the team members that provide the “secret sauce,” whose importance cannot be underestimated. It is important to approach an implementation with a full comprehension of the role of these components.

The foundational key principles of effective collaborative care include four basic elements: care that is team based, evidence based, measurement based, and population based. If these principles are met, a health care system can be reasonably assured it can be accountable for the care provided.

• Team-based care requires the addition of at least two new members including a behavioral care manager and a psychiatric consultant.

• Evidence-based care includes using approaches including brief psychotherapeutic interventions proven to work in primary care settings and psychopharmacology prescribing guidelines.

• Measurement-based care includes utilizing validated measurement tools in a systematic fashion to track patient progress. These data are used by psychiatric consultants to guide adjustments in treatment to meet defined targets such as depression remission.

• Population-based care requires taking responsibility for a defined group of patients to assure screening, repeat measurement, tracking, and engagement in care are all monitored closely, typically with a data tool called a registry.

On the basis of these principles, a list of key tasks that need to be incorporated into the workflow is determined. This is an important area of research as there are numerous tasks, yet the frequency and manner in which they are performed and by whom are not firmly established. What we do know is the frequency of contact between the patient and the behavioral care manager drives the pace of improvement, with one or more contacts a month determined to be key to success. We also know that psychiatric consultation between weeks 8 and 12 for patients who are not improving leads to change in treatment response. Systematically repeating measurement tools and keeping a registry updated with this information are crucial to providing measurement-based, treat-to-target care.

Lastly, research has demonstrated that key aspects of the personnel providing collaborative care can influence outcomes and is the “secret sauce” that goes beyond simply implementing the key tasks and re-engineered workflows. For instance, an “engaged” psychiatric consultant leads to more patients achieving remission; “buy-in” by primary care providers is crucial to patient engagement as they are on the front line in “pitching” the model to patients; primary care provider “champions” help with rallying colleagues around the model; and behavioral care managers with a well-defined role are crucial to patient engagement and ensuring key clinic tasks are performed without other distractions. Strong support from the top leadership is also necessary to provide the team resources critical to meeting defined goals as well as encouragement and support throughout the process.

Combining all of these elements can lead to success in a collaborative care program and meet targeted outcomes that are necessary to improve patient care and ready a health care system for value-based payment. Lack of attention to what we are learning about effective implementation will not. ■