In the JournalsPerspective

Set realistic timelines to help ensure collaborative care model success

Arne Beck
Arne Beck

Setting realistic timelines and fostering provider engagement were just two of the five factors utilized by collaborative care models that significantly improved patient outcomes, according to results published in the Journal of the American Board of Family Medicine.

“There is a wealth of research demonstrating the effectiveness of collaborative care models for patients with depression and diabetes and/or heart disease. However, these models have not been widely implemented because of various challenges, including the need for practice change, better care coordination between health and mental health professionals, financing and reimbursement for a care management model, among others,” Arne Beck, PhD, director of quality improvement and strategic research at the Kaiser Permanente Colorado Institute for Health Research, told Healio Family Medicine.

“Our study sought to identify some of these challenges across several diverse health care systems so that we could provide guidance for those systems interested in implementing this care model,” he added.

Beck and colleagues used site visit and survey data from eight Care of Mental, Physical, and Substance-Use Syndromes (COMPASS) care teams. These teams from eight health systems served 3,854 patients with a Public Health Questionnaire-9 Score of at least 10 and either:

  • diabetes with HbA1c of 8% or more or systolic BP of 145 mm Hg or higher; and/or
  • CVD with systolic BP of 145 mm Hg or higher.

Patients aged older than 65 years had to have both a Public Health Questionnaire-9 score greater than 10 and a systolic BP of 160 mm Hg or higher.

The care teams conducted case reviews with a consulting psychiatrist and physician weekly, reviewed a patient-tracking registry, and monitored patients’ ED and hospital use.

Five factors emerged that allowed this collaborative care model to reach its fullest potential, according to Beck.

“One, set realistic timelines. Two, foster provider engagement. Three, ensure that care management teams have the necessary skills and experience for this role. Four, determine criteria for patient enrollment in care management, and five, develop user-friendly patient tracking registries,” he said in the interview.

“We were surprised by the level of acuity, particularly the myriad of psychosocial needs, of the patients in our study,” Beck continued. “We knew they had poorly controlled depression and diabetes and/or heart disease. However, other social determinants issues arose during the care management process. This finding led us to stress the importance of assisting patients with a broader array of services outside the care setting, typically a social work function.”

He addressed family medicine doctors and primary care physicians who may be unwilling to make the change to a long-existing care model that they’ve utilized.

“The methods our health systems implemented have been shown to work in carefully controlled randomized trials. We were interested in what impediments or facilitators to implementing these methods would face across different delivery systems,” Beck said. “While we are confident that the core components of this collaborative care program are effective, the real challenge is making them work effectively in real world health care systems. Neglecting to address the various implementation barriers described in our paper would in fact decrease odds for success of the care model.”

He added the size of the study makes the findings applicable across many health care delivery systems. – by Janel Miller

Disclosures: Beck reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Arne Beck
Arne Beck

Setting realistic timelines and fostering provider engagement were just two of the five factors utilized by collaborative care models that significantly improved patient outcomes, according to results published in the Journal of the American Board of Family Medicine.

“There is a wealth of research demonstrating the effectiveness of collaborative care models for patients with depression and diabetes and/or heart disease. However, these models have not been widely implemented because of various challenges, including the need for practice change, better care coordination between health and mental health professionals, financing and reimbursement for a care management model, among others,” Arne Beck, PhD, director of quality improvement and strategic research at the Kaiser Permanente Colorado Institute for Health Research, told Healio Family Medicine.

“Our study sought to identify some of these challenges across several diverse health care systems so that we could provide guidance for those systems interested in implementing this care model,” he added.

Beck and colleagues used site visit and survey data from eight Care of Mental, Physical, and Substance-Use Syndromes (COMPASS) care teams. These teams from eight health systems served 3,854 patients with a Public Health Questionnaire-9 Score of at least 10 and either:

  • diabetes with HbA1c of 8% or more or systolic BP of 145 mm Hg or higher; and/or
  • CVD with systolic BP of 145 mm Hg or higher.

Patients aged older than 65 years had to have both a Public Health Questionnaire-9 score greater than 10 and a systolic BP of 160 mm Hg or higher.

The care teams conducted case reviews with a consulting psychiatrist and physician weekly, reviewed a patient-tracking registry, and monitored patients’ ED and hospital use.

Five factors emerged that allowed this collaborative care model to reach its fullest potential, according to Beck.

“One, set realistic timelines. Two, foster provider engagement. Three, ensure that care management teams have the necessary skills and experience for this role. Four, determine criteria for patient enrollment in care management, and five, develop user-friendly patient tracking registries,” he said in the interview.

“We were surprised by the level of acuity, particularly the myriad of psychosocial needs, of the patients in our study,” Beck continued. “We knew they had poorly controlled depression and diabetes and/or heart disease. However, other social determinants issues arose during the care management process. This finding led us to stress the importance of assisting patients with a broader array of services outside the care setting, typically a social work function.”

He addressed family medicine doctors and primary care physicians who may be unwilling to make the change to a long-existing care model that they’ve utilized.

“The methods our health systems implemented have been shown to work in carefully controlled randomized trials. We were interested in what impediments or facilitators to implementing these methods would face across different delivery systems,” Beck said. “While we are confident that the core components of this collaborative care program are effective, the real challenge is making them work effectively in real world health care systems. Neglecting to address the various implementation barriers described in our paper would in fact decrease odds for success of the care model.”

He added the size of the study makes the findings applicable across many health care delivery systems. – by Janel Miller

Disclosures: Beck reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Michael Nurok

    Michael Nurok

    Beck and colleagues’ conclusion reinforce with data what many people have suspected to be true about managing the needs of complex patient populations: That is, to have good engagement from the various caregivers you have to have a lot of trust, and staff who have understanding of the local conditions. This research looked at things at a high level, focusing on big buckets of opportunities for treating these types of patients. Though the study is helpful for any clinician who wants to ensure that their patient’s needs are met by an interdisciplinary care team, the specific aspects of how to provide care always need to be worked out in a local setting.

    I would add that in addition to what Beck and colleagues reported, caregivers need to be skilled in working in an interdisciplinary setting and be mindful of patient preferences. Physicians tend to see things from their slice of the world: for example, it is easy for a cardiologist to see the cardiology perspective uniquely, or a pulmonologist to see only the pulmonary perspective, and not focus on concerns handled by other specialties. Indeed, at times, management approaches that are good for one organ system may be detrimental to another. This is an important issue with patients with complex disease processes; take, for example, a patient with heart failure, diabetes and chronic obstructive lung disease. These are the patients for whom an interdisciplinary perspective is critical; the various perspectives on care for each of these diseases needs to be coordinated in a way that provides one simple, effective, safe and coherent approach that works for the individual patient.

     

    • Michael Nurok, MD
    • Medical director, cardiac surgery ICU
      Smidt Heart Institute at Cedars-Sinai, Los Angeles

    Disclosures: Nurok reports serving as an advisor to Avant-garde Health, a company focused on increasing value in health care delivery.

    Perspective
     Michelle B. Riba

    Michelle B. Riba

    Beck and colleagues conducted a very interesting, qualitative study that clinicians can use to learn about ways to move forward with collaborative care as part of their research.

    Here at the University of Michigan’s department of psychiatry, we also employ collaborative care, since Michigan has rural areas where there are not enough psychiatrists to meet demand, particularly specialty psychiatrists.

    One of our initiatives is called the MC3 Telepsychiatry Program, and through the years it has consisted of child psychiatrists, primary care physicians and pediatricians working together throughout the state who help each other with their respective areas of expertise. PCPs strongly agreed that MC3 was well-accepted, user-friendly, efficient, and it also increased the PCP’s confidence in managing pediatric patients with mental health concerns.

    Thus, besides Beck and colleagues’ findings, there are other studies that also suggest the collaborative care model can work in taking care of patients with multiple chronic conditions in primary care. Suggestions researchers have made regarding patient trust, using resources wisely and medical professionals working together to provide such collaborative care should be well taken.  

    • Michelle B. Riba, MD, MS
    • Clinical professor of psychiatry, University of Michigan
      Associate director, University of Michigan Depression Center
      Past president, American Psychiatric Association

    Disclosures: Healio Family Medicine was unable to determine Riba’s relevant financial disclosures prior to publication.

    Perspective
    Nicole Berelos

    Nicole Berelos

    It has been well-established that there is a strong link between the physical and behavioral health needs of people living with chronic conditions, especially diabetes. We know that we can have the best medications and great technology made available, but if the person is not vested in self-management or if there are significant competing priorities, then management of diabetes will not rise to the top of the patient’s “to-dos.”

    Primary care physicians sit at a pivotal point for both diabetes and behavioral health management as they are doing the majority of the work in this area, not the specialists. Care management has a lot of moving parts and collaborative care management tries to accomplish a lot. The work that has been done in the field has been research-based with time-limited funds and endpoint driven. While this is always the case in population health, there are many real-life variables such as sustainable payors, staff turnovers, information technology challenges, social determinants of health, provider differences such as personalities, motivation, personal buy-in, etc., perceived need and/or desire to change by the target audience, and the logistical challenges, just to name a few. This is all very overwhelming in an already taxed health care system.

    Each system, whether it be a university-based hospital, public/private hospital, community clinic, single provider private practice, etc., should to do a needs assessment that hones in on the gaps of care for those with behavioral health and diabetes comorbidities. As the model is developed, ask for input from all stakeholders including the recipients of the program — the patients. We have been seeing this with the development of medical devices and health-related apps, and it allows for valuable input early in development to help tailor programs to the intended populations and helps make the programs more relevant.

    Perhaps even narrowing the focus of the collaborative care model rather than targeting the many difficult-to-achieve factors listed in the article as it becomes overwhelming for the health care providers and the patients. Making behavior change is already difficult and focusing on a single goal is more likely to be successful than trying to attain multiple difficult goals at the same time. By hiring inter-disciplinary providers within the collaborative care model framework, all areas of diabetes management can be influenced.

    For example, health psychologists who are experts at the interplay of psychological and physical health can be key drivers at behavior change because they can approach the subject from both sides. These health care providers can serve as key moderators between physical and behavioral health which is ultimately the goal of the collaborative care model. Regardless of the approach that PCPs take in the management of comorbid diabetes and mental illness, using a person-centered approach where the person living with these conditions feels respect, valued, and heard should be the core of the care they receive.

    • Nicole Berelos, PhD, MPH, CDE
    • Licensed clinical psychologist and certified diabetes educator
      Dallas, Texas
      Spokesperson, American Association of Diabetes Educators

    Disclosures: Bereolos reports being a faculty member of the Johnson & Johnson Diabetes Institute.