In his May 2013 policy brief on the Collaborative Care Model, NIAC member Dr. Jürgen Unützer and colleagues reveal that rates of depression are 20 percent in the Medicaid population and 23 percent in the Medicaid-Medicare dually eligible population. In addition, Medicaid patients with major depression and a chronic condition (e.g., diabetes) have more than twice the overall health care costs than those without depression.
These Medicaid enrollees with comorbid mental health conditions receive poorer quality of care for their medical conditions and have mortality rates four times as high as those of the general population. A large majority of adults with these common mental health disorders receive care from primary care practices as opposed to a mental health care specialist. They prefer that primary care and mental health providers work together to treat medical and behavioral health needs.
Health homes are one way States can both “integrate primary and mental health care and pay for the essential components of enhanced care management and care coordination required for effective integration,” particularly for the Medicaid population. According to Section 2703 of the Affordable Care Act of 2010 (ACA), the Medicaid Health Home State Plan Option offers a mechanism for coordinating primary, acute, behavioral, and long-term and social service needs for Medicaid beneficiaries who have at least two chronic conditions, have one chronic condition and are at risk for another, or have a serious mental illness. Associated providers must meet all Federal and State qualifications to serve as health homes and must deliver a specific set of services across which improved integration of primary and behavioral health care delivery is an important desired outcome.
While there have been efforts to improve the treatment of common mental health disorders in primary care, some approaches have not improved patient outcomes alone or in combination, although they might be necessary parts of effective interventions. These include:
- Education of primary care providers (PCPs),
- Development of treatment guidelines and referral to mental health specialty care,
- Co-location of mental health specialists within primary care clinics, and Telephonic disease management programs.
However, evidence shows the Collaborative Care Model can effectively implement integrated care and do so under the authority of health homes. This model consists of care provided by a collaborative team that includes a PCP (i.e., a family physician, internist, nurse practitioner, or physician assistant), case management staff (i.e., nurses, clinical social workers, or psychologists), and a psychiatric consultant.
In terms of clinical practice, collaborative care programs follow measurement-based care, treatment-to-target, stepped care, and other aspects of the chronic illness care model where each patient’s progress is tracked using validated clinical rating scales (e.g., PHQ-9 for depression). Treatment is systematically adjusted or stepped up where initial adjustments are made by the primary care team with input from the psychiatric consultant. Patients who do not respond to treatment, who have an acute crisis, or who seek referral are referred to mental health specialty care. However, only a small number of patients request or are referred to specialty care.
Collaborative care has consistently demonstrated higher effectiveness than usual for different populations such as ethnic minority groups, insured and uninsured/safety-net patients, and for different mental health conditions such as depression, anxiety disorders, schizophrenia, and bipolar disorder. For instance, the IMPACT (Improving Mood -- Promoting Access to Collaborative Treatment) study, the largest trial of collaborative care to date, showed collaborative care was effective for depressed adolescents, depressed cancer patients, and diabetics, including low-income Spanish speaking patients.
In addition, IMPACT participants were more than twice as likely as those with usual care to have substantial improvement in their depression over 12 months. They also experienced less physical pain, better social and physical functioning, and better overall quality of life than patients in usual care. Patients and PCPs strongly endorsed this collaborative care model and it is cited as one of only a few studies demonstrating that patient-centered medical home (PCMH) models can achieve the Triple Aim to improve health, improve quality of care, and reduce costs. Finally, collaborative care also reduces many of these negative economic effects of depression, which, in turn, results in improved personal income, employment, and other workplace outcomes.
Implementing effective collaborative care in safety-net programs might require major change and thus create barriers such as lack of trained staff or lack of effective disease management registries. However, many large health organizations, such as the Mental Health Integration Program (MHIP) in Washington State and CareOregon, have put into practice large-scale collaborative care programs demonstrating “the applicability of the model to safety-net providers and the patients they serve.” The AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington recently convened a group of national experts to produce the “,” a consensus statement on core principles and specific functions needed to implement effective collaborative care programs.
Conveniently, the Collaborative Care Model is an approach to integration that can be expanded to address a broader range of beneficiary needs. For example, Minnesota’s DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) program used the key components of collaborative care to develop fuller PCMHs. Moreover, the new health homes service promotes the opportunity to adapt effective evidence-based models of care that define health home services and provider qualifications. Thus, States can use this Collaborative Care Model “as a building block for health homes and other initiatives that aim to better integrate care for Medicaid beneficiaries with chronic physical and behavioral health needs.”