VA Study Shows Path Toward Sustainable CoCM Implementation

Numerous lines of research have shown that the Collaborative Care Model (CoCM)—a model that integrates care across different teams—improves the outcomes of people with psychiatric illness. However, the question remains: Can collaborative care models be implemented and sustained in real-world settings?

A study recently funded by and conducted at nine U.S. Department of Veterans Affairs (VA) mental health clinics suggests the answer is yes. The researchers found that a CoCM focused on team building and improved communication could be implemented with minimal external support and provide benefits to both staff and patients. The findings were posted March 1 in JAMA Network Open.

Lead study author Mark Bauer, M.D., a professor of psychiatry at Harvard Medical School and investigator at the VA Center for Healthcare Organization and Implementation Research, became interested in the area of implementation science about a decade ago after conducting clinical research on CoCMs to improve the management of bipolar disorder. The models showed promise at improving the long-term health of bipolar patients, but when Bauer went back to the participating clinics after the study had completed, he found none of them had taken up the model full time.

The problem, Bauer realized, was that clinical studies bring in lots of external resources to a health care center and create a short-term, controlled environment that can adequately test a hypothesis. But momentum evaporates along with those resources once the trial with its associated support ends, and entropy inevitably takes over.

“To become a routine part of practice, health clinics have to introduce collaborative care in a way that’s sustainable,” said Bauer. That means structured introduction of collaborative care concepts, minimal external support, and a flexible protocol as opposed to cookbook-style instructions.

To test such an implementation process, Bauer and colleagues recruited VA mental health clinics from across the country, including some rural areas, to participate in the study for one year. Each clinic chose one internal staff member to act as a facilitator in the implementation process and work alongside an external facilitator. There were three external facilitators in total who split their time between three clinics each, while the internal facilitators were asked to devote 10% of their time to help set up the new model of care. The remaining staff had to commit to only a one-hour meeting each week to learn collaborative care processes.

“The only new funding required was that needed to support the three external facilitators,” Bauer said. “Everything else was accomplished by rearranging the furniture.”

The basic tenets of the study’s CoCM were to improve communication and better define the roles of each staff member to build a more cohesive team. As Bauer explained to Psychiatric News, there was no specific protocol. Rather, each clinic devised its own set of processes in response to the 27 commonly-defined criteria of effective collaborative care.

Over two years, 5,596 veterans were seen at participating VA clinics. The average symptom scores among all patients in the study did not significantly improve, which Bauer said was not too surprising for a diverse sample that included veterans with a host of psychiatric disorders ranging from mild to severe. However, there was a robust reduction in the number of patients who required inpatient hospitalization. Also, the researchers found significant symptom improvements among veterans classified as having “complex clinical symptoms” (three or more psychiatric diagnoses in the previous year).

Surveys of the staff showed that implementing collaborative care processes improved their understanding of their roles at the clinic and the importance of teamwork. In terms of implementing all 27 collaborative care processes, site achievement varied from 44% to 89%.

“The results could be described as mixed, but I think that the answer to whether a mental health clinic should deploy a collaborative care model is yes, particularly for individuals with or at-risk of complex symptoms,” Bauer said. “The outstanding issue becomes how to optimally introduce collaborative care. Do you deploy it clinic-wide right away, or in a stepped-care fashion where you focus on more severe patients first?”

That question might be answered in the near future. The VA announced that based on the study data, the agency plans to implement this team-based model of care nationally over the next two years. ■