April 2, 2014

Experiences in Implementing Collaborative Care

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Katherine Sanchez, LCSW, PhD

The University of Texas at Arlington, Arlington


Wagner’s Chronic Care Modelof disease management applied to the treatment of mental disorders in primary care has come to be known as integrated health care or collaborative care. The model is a systematic approach that involves integration of patient oversight by mental health specialists, care managers, and primary care physicians to proactively treat mental health disorders. That systematic integration of various disciplines moves team practices beyond parallel relationships to an interdisciplinary practice model that includes collaborative communication, collective action, a process orientation, and working together for common goals that are centered on whole-person care.

Our recent qualitative case study of an integrated health care model of service delivery for the treatment of depression in a low-income, uninsured adult population explored how a collaborative care model of service delivery works. We examined a single, interdisciplinary team of providers to explore how the integrated health care model of collaborative care was an effective strategy for providing mental health treatment to a predominantly Hispanic patient population at one grant-funded primary care safety-net clinic.

There is little doubt that the mental health treatment community has historically played a role in obstructing communication between providers, in the interest of protecting patients and advocating for privacy as it related to mental health diagnoses. However, despite common protests among professionals about private health information and the sharing of mental health records, in our study, the care manager expressed surprise at never meeting a patient who was concerned about who might gain knowledge about his or her mental disorder. In fact, she summarized, “They felt like, ‘I’ve got this team of people around me that care about me, that are all communicating.’ It’s like being a well-loved child.”

Another historical obstacle to collaboration between providers has been the influence of the traditional medical model, in which the primary care doctor maintains control of patient care and struggles with sharing responsibility, except to hand off care to a psychiatrist. Skepticism that collaborative care will create more work for the primary care physician is a common reaction to the implementation of the collaborative care model. In our clinic, we took several steps to combat resistance. A respected, experienced physician was asked to champion the model to skeptical physicians, and then the clinical social worker who was acting as care manager shadowed physicians during patient visits to learn their styles. Finally, our early focus on identifying the most problematic patients of each physician, who were then successfully treated with the assistance of the care manager, also helped build trust and ease the medical team into understanding and using the model.

The development of patient-centered collaborative care teams is a core tenet of health care reform, at a time when the culture of cross-education and training is quite limited. Collaboration requires team members from various disciplines to develop a common language, loosen hierarchical structures, pool bodies of knowledge and theories, and jointly develop new methods and analytical techniques within a philosophy of whole-person care. In this sense, the patient is also considered a vital part of the team. Without a doubt, collaborative care teams offer the best hope for achieving quality health care outcomes, particularly for vulnerable populations and patients with multiple comorbidities.

Financial disclosure:Dr Sanchez had no relevant personal financial relationships to report.

Category: Medical Conditions , Mental Illness
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6 thoughts on “Experiences in Implementing Collaborative Care

  1. The mode; makes a lot of sense. In psychiatry we prescribe medicines that may increase lipids, cause obesity, increase blood pressure, cause or aggravate diabetes or cause neutropenia. Our medicines may have dangerous interactions with various non-psychiatric medications. Many bad things thar happen to patients would be minimized by a collaborative care model. In psychiatry it is difficult to comply with the maxim “primum non nocere ” in the absence of a collaborative care model.
  2. As the vast majority of physicians do not learn much after residency, this style of practice has to engrained during the learning phase. Residents in all areas of medicine should spend time in psychiatric clinics and hear lectures on the common neuroses which they are bound to encounter.
  3. As a psychiatric NP, I work actively in two PCMH that are primarily commercial based insurance. The work is very stimulating and find the Primary Care Providers value my feedback on difficult patients, and missed many diagnosis. Psychologists or social workers work with me, doing CBT and other direct mental health services. It is a great model of care. We have a psychiatrist that I collaborate with for more difficult cases, or ones that are treatment resistant. We have improved access and made a significant improvement in care.
    Please consider this a good role for employing psychiatric NP’s!
  4. In brazil we have a special type of collaborative care model named “matrix support teams”, that go regularly to PC units where Family health teams (nurse, family doctor, nurse tecnician and six community agents) that take care of a community around 4000 people. The prevalences of common mental disorders are extremely high as these units are usually located in very deprived communities. As Psychiatry in one of these matrix support teams teams we work with residents for Family Medicine and Psychiatry and I agree that we need to teach people in this new type of work process.
    We do not have case managers as in the Collaborative Care traditional model. It is the community worker that follow more closely all his 150 families and usually bring cases to the doctor and nurse.
    But we need to develop new models of psychosocial interventions that could aid these people overcome the difficult life conditions that are associated with the presence of common mental disorders.
    Developing these interventions and offering therapeutic and support alternatives besides individual psychological treatment only is a challenge to collaborative care.

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