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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
An integrated, collaborative model for more comprehensive patient care
Creating Effective Mental and Primary Health Care Teams provides the practical information, skills, and clinical approaches needed to implement an integrated collaborative care program and support the members of the care team as they learn this new, evidence-based, legislatively mandated care delivery system. Unique in presenting information specifically designed to be used in an integrated, collaborative care workflow, this book provides specific guidance for each member of the team. Care managers, consulting psychiatrists, primary care providers, and administrators alike can finally get on the same page in regard to patient care by referring to the same resource and employing a common framework. Written by recognized experts with broad research, clinical, implementation, and training experience, this book provides a complete solution to the problem of fragmented care.
Escalating costs and federal legislation expanding access to healthcare are forcing the industry to transition to a new model of health care delivery. This book provides guidance on navigating the changes as a team to provide the best possible patient care.
- Integrate physical and behavioral care
- Use evidence-based treatments for both
- Exploit leading-edge technology for patient management
- Support each member of the collaborative care team
Strong evidence has demonstrated the efficacy of a collaborative care approach for delivering mental health care to patients in a primary care setting. The field is rapidly growing, but few resources are available and working models are limited. This book provides a roadmap for transitioning from traditional methods of health care to the new integrated model. Providers ready to move to the next level of care will find Creating Effective Mental and Primary Health Care Teams an invaluable resource.
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Veröffentlichungsjahr: 2016
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Table of Contents
Cover
Title Page
Copyright
Dedication
Preface Using Collaborative Care to Create Effective Mental and Primary Health Care Teams
What is Collaborative Care?
Book structure
Toolkit inventory checklist
Acknowledgments
Chapter 1: Working as a Team to Provide Collaborative Care
Collaborative Care team roles
Collaborative Care shared workflow
Core Collaborative Care skills and tools
Collaborative Care assessment
Collaborative Care treatment
Part 1: Collaborative Care for Common Primary Care Presentations
Chapter 2: Mood Disorders—Major Depression
Clinical impact
Assessment
Treatment
Special considerations for adolescent depression
Resources for providers
Resources for patients
References
Chapter 3: Bipolar Disorder
Clinical impact
Assessment
Resources for providers
Resources for patients
References
Chapter 4: Anxiety and Trauma Disorders
Clinical impact
Assessment
Treatment
Resources
References
Chapter 5: Psychotic Disorders
Clinical impact
Assessment
Treatment
Web resources
References
Chapter 6: Substance Use Disorders: Alcohol, Stimulants, and Opioids
Clinical impact
Assessment
Treatment
Web resources
References
Chapter 7: Chronic Pain
Clinical impact
Assessment
Treatment
Self-help books and web resources
References
Chapter 8: Attention Deficit Hyperactivity Disorder (ADHD)
Clinical impact
Assessment
Treatment
Resources
References
Part 2: Collaborative Care Interventions
Chapter 9: Challenging Clinical Situations
Clinical impact
Assessment
Treatment
Summary
References
Chapter 10: Evidence-Based Behavioral Interventions for the Collaborative Care Team
Overview
Core skills
Engagement strategies
Crisis management
Treatment
Relapse prevention
Summary
Resources
Chapter 11: Evidence-Based Psychopharmacology for the Collaborative Care Team
Overview
Brief medication prescribing protocols
Antidepressant medications
Anxiolytics & hypnotic medications
ADHD medications
Miscellaneous medications
Mood stabilizers
Antipsychotics
References
Online resources
Article
Textbook
Appendix: Resources
Screeners
Online Content Available
About the Authors and Contributors
Index
End User License Agreement
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Guide
Cover
Table of Contents
Begin Reading
List of Illustrations
Chapter 1: Working as a Team to Provide Collaborative Care
Figure 1.1 Model integrated behavioral health team: There are two new roles added to the primary care setting, a behavioral health provider and a psychiatric consultant. The solid arrows indicate regular communication and the dashed arrows represent as-needed communication.
Figure 1.2 Typical timeline of treatment in Collaborative Care.
Figure 1.3 Tasks of Collaborative Care.
Chapter 7: Chronic Pain
Figure 7.1 Pain assessment questionnaire (PEG three item scale & activity limitation).
Chapter 10: Evidence-Based Behavioral Interventions for the Collaborative Care Team
Figure 10.1 The psychotherapeutic process can move between stages over the course of treatment, but each stage must be addressed for treatment to be effective both at the team and individual provider levels.
List of Tables
Chapter 1: Working as a Team to Provide Collaborative Care
Table 1.1 Generating a differential diagnosis
Table 1.2 Common conditions in primary care
Chapter 2: Mood Disorders—Major Depression
Table 2.1 Generating the differential diagnosis for depressive disorder
Table 2.2 Common depressive disorders in primary care (ICD-10)
Table 2.3 Team-based treatment for depression in primary care
Table 2.4 Medications commonly used in the treatment of depression
Chapter 3: Bipolar Disorder
Table 3.2 Common bipolar disorders in primary care (ICD-10)
Table 3.1 Generating the differential for bipolar disorder
Table 3.3 Team-based treatment for bipolar disorder
Table 3.4 Medications commonly used in the treatment of bipolar disorder
Chapter 4: Anxiety and Trauma Disorders
Table 4.1 Generating the differential for anxiety disorders
Table 4.2 Common anxiety disorders in primary care (ICD-10)
Table 4.3 Team-based treatment for anxiety
Table 4.4 Medications commonly used in the treatment of anxiety disorders
Table 4.5 Benzodiazepines commonly used in the treatment of anxiety
Chapter 5: Psychotic Disorders
Table 5.1 Generating the differential for psychotic disorders
Table 5.2 Possible psychotic disorders in primary care (ICD-10)
Table 5.3 Team-based treatment for psychosis
Table 5.4 Medications commonly used in the treatment of psychosis
Table 5.5 Communication strategies with patients with psychosis
Table 5.6 Medications to treat extra pyramidal symptom side effects
Chapter 6: Substance Use Disorders: Alcohol, Stimulants, and Opioids
Table 6.1 Screening and assessment for substance-use disorders
Table 6.2 Common substance-use disorders in primary care (ICD-10-CM)
Table 6.3 Team-based treatment for substance use in primary care
Table 6.4 Medications commonly used in the treatment of alcohol, opioid, and stimulant use disorders
Chapter 7: Chronic Pain
Table 7.1 Differential for common causes of chronic pain syndromes
Table 7.2 Common chronic pain syndromes in primary care (ICD-10)
Table 7.3 Team-based treatment for chronic pain
Table 7.4 Medications commonly used in the treatment of chronic pain
Table 7.5 Antidepressants commonly used in the treatment of chronic pain
Chapter 8: Attention Deficit Hyperactivity Disorder (ADHD)
Table 8.1 Generating the differential for ADHD in adults
Table 8.2 Generating the differential for ADHD in children
Table 8.3 Common ADHD disorders in primary care (ICD-10)
Table 8.4 Team-based treatment for ADHD
Table 8.5 Medications commonly used in the treatment of ADHD
Table 8.6 Other medications commonly use in pediatric populations
Chapter 9: Challenging Clinical Situations
Table 9.1 Common difficult situations in primary care
Table 9.2 Potential pitfalls in naming the emotions that working with the patient evokes in you
Table 9.3 Common problematic patient behaviors
Table 9.4 Common problematic provider behaviors
Table 9.5 Effects of common problematic provider behaviors
Table 9.6 Strategies for typical difficult situations
Table 9.7 Potential pitfalls to developing a team-based behavioral approach to addressing the difficult situation
Chapter 10: Evidence-Based Behavioral Interventions for the Collaborative Care Team
Table 10.1 Core skills BHPs should have as an effective Collaborative Care team provider
Table 10.2 Engagement strategies for Collaborative Care
Table 10.3 Distress tolerance strategies BHPs should have as an effective Collaborative Care team provider
Table 10.4 Specific evidence-based behavioral interventions for primary care Collaborative Care teams
Table 10.5 Relapse prevention planning
Chapter 11: Evidence-Based Psychopharmacology for the Collaborative Care Team
Table 11.1 Quick reference guide: Commonly prescribed psychotropic medications
IntegratedCare
Creating Effective Mentaland Primary Health CareTeams
Anna Ratzliff
Jürgen Unützer
Wayne Katon
Kari A. Stephens
University of Washington School of Medicine, Seattle, Washington, USA
Copyright © 2016 by John Wiley & Sons, Inc. All rights reserved.
Published by John Wiley & Sons, Inc., Hoboken, New Jersey.
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Library of Congress Cataloging-in-Publication Data
Ratzliff, Anna, 1972–, author.
Integrated care : creating effective mental and primary health care teams / Anna Ratzliff, Jürgen Unützer, Wayne Katon, Kari A. Stephens.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-118-90002-4 (pbk.), 978-1-118-90004-8 (e-PDF), and 978-1-118-90003-1 (e-Pub)
I. Jürgen Unützer, author. II. Katon, Wayne, author. III. Stephens, Kari Astley, author. IV. Title.
[DNLM: 1. Mental Health Services. 2. Primary Health Care—methods. 3. Delivery of Health Care, Integrated—methods. 4. Evidence-Based Medicine—methods. 5. Mental Disorders—drug therapy. 6. Patient Care Team. WM 30.1]
RA418
362.1—dc23
Cover design by Wiley
Cover image: ©iStock.com/Jeja
We dedicate this book to the memory of Wayne Katon, our friend, colleague and mentor. Wayne's research and clinical work for more than three decades helped establish the evidence-base for collaborative care and his ongoing mentorship gave us the practice experience and support to write this book.
—Anna Ratzliff, Jürgen Unützer, Kari A. Stephens
Preface
Using Collaborative Care to Create Effective Mental and Primary Health Care Teams
Anna Ratzliff, Wayne Katon, and Jürgen Unützer
What is Collaborative Care?
Collaborative Care is more than just bringing a mental health provider to a primary care setting. In Collaborative Care, a team of providers, including the patient's primary care provider, a behavioral health provider or care manager, and a psychiatric consultant, work together to provide evidence-based mental health care to populations of patients. To provide Collaborative Care, a group of providers must function as a team and share a workflow to provide evidence-based mental health.
Evidence-Based Care
: A large body of evidence shows that Collaborative Care improves mental health outcomes in primary care settings. This approach has been recommended as a best practice by the Surgeon General's Report on Mental Health and the President's New Freedom Commission on Mental Health.
Not Care as Usual
: Before starting a Collaborative Care program, a team must develop a clear sense of what kind of care will be provided and how success will be measured.
What makes Collaborative Care effective? The principles of Collaborative Care
Although programs may vary in how their team works together, expert consensus suggests that to be effective Collaborative Care addresses the following five principles.
Patient-Centered Team Care
: A team of providers effectively work together to provide patient-centered care using a shared care plan.
Population-Based Care
: Tracking all patients receiving care proactively through a registry so no patients “fall through the cracks.”
Measurement-Based Treatment to Target
: Systematic use of clinical outcome measures to support treatment and treatment adjustments.
Evidence-Based Care
: Delivery of evidence-based psychosocial and pharmacological treatments.
Accountable Care
: The team and the health care organization are responsible for individual patients and patient populations reaching treatment targets and conduct ongoing quality improvement.
How can this book support the work of a Collaborative Care team?
This book is designed to help teams work together to assess for and treat patients with common mental health disorders in a primary care setting. Although many of the evidence-based treatments used to treat common mental health disorders are discussed in subsequent chapters, this book is not meant to be a comprehensive guide on how to deliver all aspects of care. This book models how the tasks required to successfully assess and treat patients for common mental health disorders can be shared by a team using Collaborative Care. Additionally, this book:
Helps teams develop integrated workflows and facilitate effective communication about common clinical problems that the team will encounter.
Can be shared by the whole team so that each team member may better understand the work of the other team members.
Focuses on adult populations. Although there are Collaborative Care models for pediatric populations, the majority of conditions and treatments reviewed here are for adult populations.
Provides a quick overview of each team member's role in assessment and treatment in each chapters' “working as a team” boxes.
Offers quick access to answers to the following common questions when sharing a clinical workflow:
What is my role in the care of this patient?
How will the other team members work with the patient?
How can we share care more effectively?
This book is designed for a Collaborative Care team that is already working together. If you have not yet started working as a team, a more formal team building process will be an important first step to form a Collaborative Care Team. We encourage you consider looking at the following resources:
UWAIMS Center
:
http://aims.uw.edu/
Qualis Safety-Net Medical Home Initiative
:
http://www.safetynetmedicalhome.org/change-concepts
SAMSHA/HRSA
:
http://www.integration.samhsa.gov/workforce/teammembers
How would this patient be treated in the clinic system you work in?
This book will help your team provide a structured, team approach, providing effective care for the common mental health disorders encountered in primary care settings. As an introduction to this book we want you to consider the following patient and the care the patient would receive in your clinic setting.
Case
Mr A, 31-year-old male, presents to his primary care doctor asking for “sleeping pills.” His PCP takes a history and finds out he has not been sleeping well for the last month, he has been struggling to get work and missed a few days, he has difficulty concentrating and his wife is frustrated because he has “just checked out.” His PCP suspects he may be experiencing depression.
How much of this patient's care would you be able to provide in your primary care setting?
Which providers would work with this patient? Would you work as a team?
How would you make a diagnosis?
Do you have a system to make sure he would not “fall through the cracks” if he missed a follow-up appointment?
How would you track his response to treatment?
Do you have experience with the evidence-based treatments you might need to treat him to achieve remission?
What tools and resources would you use to help you treat him?
Do you have a system in place to monitor the quality of care delivered at your clinic?
Now consider how the Principles of Collaborative Care can influence Mr. A's treatment:
Case example
Patient centered team care
: Mr. A's PCP introduces him to Collaborative Care and the idea that a team of providers will work with him to provide care for his depression right in the primary care clinic. That very first day he meets his Care Manager (a licensed behavioral health professional), starts a mental health assessment and is offered information about depression treatment options. His Care Manager also recognizes how much Mr. A's sleep disturbance is bothering him, so she discusses sleep hygiene with him on that first visit.
Population-based care
: The Care Manager enters Mr. A into the clinic patient registry. This is an important step because Mr A missed his follow-up visit due to oversleeping. His Care Manager is able to engage Mr A over the phone to return for follow-up care at the next available appointment. This approach allows the team to track all the current patients being followed for depression in the clinic and make sure no patients “fall through the cracks.”
Measurement-based treatment to target
: At every visit, Mr A's team makes sure he completes a depression measure (in this case the Patient Health Questionaire-9) to assess the severity of his symptoms. Mr A is started on antidepressant medication but needs several adjustments before this medication is effective. Using measurement to assess depression helps the team make decisions about when to intensify treatment.
Evidence-based care
: After the initial assessment, Mr A's Care Manager discusses his case with the psychiatric consultant by presenting his case over the telephone. Although the psychiatric consultant does not meet Mr A, the psychiatric consultant is able to provide guidance about evidence-based medication treatment and brief behavioral interventions validated for use in primary care to treat depression. The psychiatric consultant is also available to provide guidance to the PCP about intensification of medication treatment for Mr A's depression.
Accountable care
: On the patient level, the whole team is committed to adjusting Mr A's treatment until his depression symptoms are significantly improved. At an organizational level, the team that takes care of Mr A engages in regular quality improvement efforts. For example, when they examine their data on follow-up visits, the team realizes that many patients miss their early follow-up visits. The clinic begins a program to track follow-up visits and make outreach phone calls for missed appointments. These quality improvement efforts provide the accountability the clinical team needs to systemically improve outcomes.
Mr A's depression goes into remission, and he is able to continue working and improve his relationship with his wife. By using Collaborative Care, Mr. A's team is able to deliver high-quality care that improves outcomes, is associated with high patient satisfaction, and contains cost.
Book structure
Each of the clinical chapters in this book follows a format designed to make it easy for the clinical team to work together to assess and treat patients. Readers performing any of the roles on a Collaborative Care team can read this book and learn practical skills from its case examples. Each chapter will start with a general overview of the condition in the Clinical Impact section. Team assessment is often a new skill for providers who have generally completed this step on their own. The Assessment section breaks the patient assessment process down into two phases. Finally, the Treatment section breaks down treatment into the three phases.
The Working as a Team sections provide a sample case and an outline of how a team can share the assessment and treatment responsibilities. More detailed resources on the evidence-based treatment for common psychiatric disorders exist, and this book is no replacement. Rather our chapters outline principles unique to a Collaborative Care team approach to assessment and treatment in a primary care setting. Special attention is devoted to highlighting how the principles of Collaborative Care may be incorporated into the treatment process. Additional information about effective treatment strategies for the Collaborative Care team is reviewed in two chapters: Chapter 10, “Evidence-Based Psychopharmacology for the Collaborative Care Team,” and Chapter 11, “Evidence-Based Behavioral Interventions for the Collaborative Care Team.”
Toolkit inventory checklist
Team members working together to provide Collaborative Care as a team is often a new way of working. The following checklist can be helpful in assessing if your team has all the tools and skills needed to begin working as a Collaborative Care team. This list is not comprehensive, but gives a categorical list of basic tools, procedures, and protocols needed across the team to be effective.
Collaborative Care toolkit inventory
Principles
Toolkit inventory
Yes?
For more information
Patient-Centered Team Care
Introducing the Integrated Care Team Approach
Chapter 1
Team Communication Strategies
Chapter 1
Psychoeducation
Chapter 1
, Diagnosis Specific Chapters
Team Goal Setting
Chapter 1
,
Chapter 10
Population-Based Care
Effective Engagement
Chapter 10
Registry Tracking
Chapter 1
, Appendix
Caseload Management
Chapter 1
Tracking and Treatment to Target
Use of Behavioral Health Measures
Chapter 1
, Diagnosis Specific Chapters, Appendix
Measurement Based Practice
Chapter 1
, Diagnosis Specific Chapters
Stepped Care Approach
Chapter 1
, Diagnosis Specific Chapters
Evidence-Based Practices
Differential Diagnosis Techniques
Chapter 1
, Diagnosis Specific Chapters
Evidence-Based Behavioral Interventions
Diagnosis Specific Chapters,
Chapter 10
Evidence-Based Psychopharmacology
Diagnosis Specific Chapters,
Chapter 11
Suicidal and Homicidal Protocols
Online Materials
Crisis Management
Chapter 9
, Online Materials
Accountable Practice
Quality Improvement Goals
Chapter 1
Quality Improvement Approach
Chapter 1
Acknowledgments
“We thank the many patients and providers who have worked with us to learn how to deliver more effective mental health care in primary care settings and inspire us to continuously to improve the care we deliver.
“We also would like to thank the AIMS Center staff with special appreciation to Lindsay Baldwin, Melissa Farnum, Alan Godjics, Andrea Panniero and Rebecca Sladek for their support in this effort.”
Chapter 1Working as a Team to Provide Collaborative Care
Anna Ratzliff, Joseph Cerimele, Wayne Katon, and Jürgen Unützer
Effective integration of mental and primary health care requires the effective sharing of tasks among members of a Collaborative Care team that works together with the patient as the center of the team's efforts. This chapter reviews typical team-member roles, a model of a shared clinical workflow, and core Collaborative Care skills and tools.
Collaborative Care team roles
Focusing on the function, rather than title or previous role, of team members ensures that all the critical tasks of a Collaborative Care program are delivered to provide effective patient care. A formal team-building process can facilitate Collaborative Care implementation. Common roles on a Collaborative Care team include (Figure 1.1):
Patient
The most important person on the team!
Works with the primary care provider (PCP) and the behavioral health provider (BHP)/care manager (CM).
Reports changes in health, symptoms, and functioning.
Sets goals for treatment with the team.
Tracks clinical progress using patient-reported outcome measures.
Asks questions and discusses concerns about care.
Understands treatment plan, including goals of behavioral interventions and names/doses of medications.
Primary care provider (PCP)
Clinician degrees may include MD, DO (doctor of osteopathic medicine), ARNP (advanced registered nurse practitioner), and NP (nurse practitioner).
Oversees all aspects of patient's care.
Introduces Collaborative Care team, often with “warm handoff.”
Diagnoses common mental disorders.
Prescribes medications to treat psychiatric illnesses as appropriate.
Adjusts treatment in consultation with BHP/care manager, psychiatric consultant, and other behavioral health providers.
Behavioral health provider (BHP)
Clinician degrees may include MSW, LCSW, RN, MA, PhD, and PsyD.
Works closely with PCP and helps manage a caseload of patients in primary care (care manager).
Facilitates patient engagement and education.
Performs structured initial and follow-up assessments.
Systematically tracks treatment response using behavioral health measures.
Provides brief, evidence-based behavioral interventions or refers to other BHP for these services.
Supports medication management by PCPs.
Helps patient identify where to get medications.
Encourages and supports medication adherence.
Brings concerns about medications or side effects to PCP, and schedules PCP visit to adjust treatments as appropriate.
Reviews challenging patients in systematic, weekly case review with the psychiatric consultant.
Facilitates referrals to other services (e.g., substance abuse treatment, specialty care, and community resources) as needed.
Prepares patient for relapse prevention.
Psychiatric consultant (PC)
Psychiatrist or other expert in psychiatry and psychopharmacology.
Supports PCPs and BHPs, providing regular (weekly) and as-needed consultation on a caseload of patients followed in primary care.
Focuses on patients who are not improving and who need treatment adjustment or intensification.
Available to provide in-person or telemedical consultation or, for complex or persistently ill patients, referral.
Provides education and training for primary care providers and BHPs as appropriate.
Other behavioral health providers
These may include chemical dependency counselors or other licensed behavioral health professionals.
Deliver specialized evidence-based counseling/psychotherapy (individual or group).
Support behavioral health interventions focused on health behaviors.
Provide chemical dependency counseling/treatment.
Facilitate other mental health or substance abuse services.
Other partners important to include in team building
CEO, administrators, medical directors, clinic managers.
Medical and mental health leaders/champions.
Receptionists/front desk staff, medical assistants.
Figure 1.1 Model integrated behavioral health team: There are two new roles added to the primary care setting, a behavioral health provider and a psychiatric consultant. The solid arrows indicate regular communication and the dashed arrows represent as-needed communication.
Collaborative Care shared workflow
A typical course of Collaborative Care will involve contributions from the entire team over a relatively short period of time. Figure 1.2 shows a typical course of Collaborative Care for a common mental health disorder, such as depression. Patients will be identified, assessed, and treated, and complete an episode of care, including relapse prevention.
Figure 1.2 Typical timeline of treatment in Collaborative Care.
Figure 1.3 shows common tasks accomplished as part of Collaborative Care. Some clinics may add additional tasks to meet the needs of specific populations or to target specific health problems. For each task, a team will need to decide how, when, where, and by whom the task will be completed as part of a shared workflow. A shared clinical flowchart can be useful to illustrate the process of care when a patient comes to the clinic. Handoffs and communication among team members require special attention. Every clinic's flowchart will be unique.
Figure 1.3 Tasks of Collaborative Care.
Core Collaborative Care skills and tools
Skills training (summarized below) will need to be completed before launching a Collaborative Care program.
Introducing the Collaborative Care team approach to the patient
It is important to introduce the patient to the concept of team-based care and to explain how a team of providers will work together to deliver care in the familiar primary care setting. One of the best ways to do this is to have the PCP introduce the patient to the BHP in person, providing a “warm handoff.” Another communication strategy is to use a flyer to introduce the care team and each team member's role.
Key information to be shared with the patient:
The patient is an important member of the team.
All team members will share one treatment plan to support patient-centered goals.
The PCP will oversee all aspects of patient care at the clinic.
The care manager works closely with the patient and the PCP to implement a treatment plan, including keeping track of treatment progress and providing counseling.
The psychiatric consultant does not see all patients in person but provides valuable expertise to guide treatment for all patients.
Team functioning
Sharing care is often a new skill for care-team members. Effective communication is fundamental to providing high-quality shared care. One of the major challenges to team function around behavioral health is that providers have often trained in “cultures” with different orientations. This culture clash can make it difficult to plan and implement truly integrated behavioral health plans, unless effective team building occurs.
Key strategies to strengthen team functioning include:
Sharing goals
: Describe a clear set of behavioral health goals at the organization level. At the patient level, the goal is to have one treatment plan that is shared by all team members. This will often require practical troubleshooting in how to document and share information in electronic medical record systems.
Building mutual trust
: Consider opportunities to foster mutual trust and skill building among the care team. Sharing patient success stories and challenges at provider meetings can strengthen team members' commitment to sharing care.
Clarifying roles and workflow
: Taking time to establish clear roles and shared workflows is important to support effective teamwork. Workflows should be regularly reviewed as a team to identify areas in which additional problem solving is needed.
Strengthening communication strategies
: Agree on communication strategies, including in-person communication, tasking or electronic communication, or using the electronic medical record. Consider daily or weekly huddles to facilitate rapid team communication around challenging patients and organizing team priorities.
Accountable practice
The core concept of accountable clinical care is identifying goals, defining ways to measure those goals, and then regularly reviewing progress toward goals. Accountable practice is key for effective Collaborative Care at the patient and population levels. Common targets for behavioral health teams include access to care, number of patients served, patient satisfaction, patient-reported outcomes using standard measurements (such as the Patient Health Questionnaire, or PHQ-9, for depression), and costs. Many teams find using familiar quality-improvement strategies, such as a Plan-Do-Study-Act (PDSA) cycle, helpful in supporting accountable practice.
Key strategies for accountable care include:
Identify goals
: All team members should have a clear understanding of both patient- and program-level goals.
Define measurements
: Identify key measurements and strategies to obtain data on these measures in your organization.
Review progress
: Regular review of data can help all team members identify areas for improvement. If real-time data on key measures are available, any member of the behavioral health team can examine current data on both process and outcome data to assess progress toward shared goals. This allows teams to nimbly respond to unmet goals.
Registry
A registry is a list of all the patients currently being cared for by a provider or clinic, and is used to keep track of a defined population of patients. Registries allow teams to track patient progress and to reach out to patients who have been identified in the registry as needing help but may have “fallen through the cracks.” This concept may be familiar to primary care practitioners, as many clinics keep registries for other chronic medical conditions, such as diabetes. Using a registry, or having the ability to proactively engage patients in care when they have been “lost to follow-up,” is especially important with mental health disorders such as depression and anxiety, as symptoms of these disorders often include isolation and low motivation. (See online materials for more information on registries.)
Key strategies for effective registry use:
Typically, each patient is assigned to a specific behavioral health care manager. Date of enrollment, dates of follow-up contacts, and scores on outcome measures (such as the PHQ-9) are examples of information commonly included in a registry.
More sophisticated registries have such capabilities as reporting percent improvement for a patient, percentage of the entire patient panel population improved, or reminders for key clinical processes.
Collaborative Care assessment
This information is not meant to replace detailed resources on patient assessment; rather, this book outlines principles for how a team can share assessment of patients in primary care. Special attention is devoted to highlighting how Collaborative Care principles may be incorporated into the assessment process.
Identify chief complaint, associated somatic and psychological symptoms, functional impairment, and safety concerns
Clinicians will identify patients either when they present with symptoms of a mental health disorder or through routine screening of patient populations. The PCP and CM work together to gather enough history to generate a differential diagnosis.
Measures
: Consider using standard measures to assess common symptoms, such as depression and anxiety symptoms. Some measurement tools can also be used to track response to treatment.
Past mental health history
: Number and severity of previous mental health episodes, and experience with mental health treatments.
Current and past history of alcohol or substance use
: Use of prescription or nonprescription drugs or alcohol. History of prior substance abuse treatment.
Common psychological symptoms
Mood and anxiety symptoms, enjoyment/quality of life, relationships, social activities, work or employment status, hobbies, and sex.
Common physical/Somatic symptoms
Physical symptoms such as acute or chronic pain; physical activities such as walking, eating, and sleeping; and side effects of medications.
Common functional impairments
Activities of daily living (how does the patient spend his/her day?). How are symptoms impacting function?
Assessment of safety
All team members should remember this important part of assessment.
Self-harm
: Self-harm or suicidal ideation, or history of suicide attempts or other self-harm, such as cutting, or other high-risk behaviors.
Thoughts of harming others and other safety risks
: Serious inability to care for self (grave disability) and environmental or social issues posing safety risks: housing/shelter risks, violence (i.e., domestic violence and other dangerous social circumstances).
Team goal: Identify the chief complaint, initial physical exam, gather history, and safety assessment
In most clinics, the PCP will conduct the preliminary steps as part of routine care and then refer to the BHP for additional assessment. Some clinics may opt to routinely screen vulnerable patient populations for common mental health and substance use problems. Especially important will be to plan for consistent safety assessment by all clinic staff.
Working as a team
Patient: Describes symptoms, how symptoms impact daily life, desired treatment goals, and relevant history, such as prior treatments, to the PCP and BHP. Completes measurement tools as part of initial assessment. Shares symptoms of past and current suicidal ideation with the treatment team, informs the team if symptoms worsen. Shares psychosocial and risk factors with the treatment team.
PCP: Gathers health history, conducts physical exam, reviews results from diagnostic studies, and begins to formulate an assessment. Fosters a therapeutic alliance with the patient, introduces the team approach to behavioral health, and provides an introduction to the BHP. Assesses for safety, coordinates with BHP to monitor safety issues and implement treatment plan.
BHP: Completes detailed assessment of psychiatric, social, and substance use history; use of coping strategies; and readiness to engage in self-management. Prompts patient to complete measurement tools. Assesses safety issues and helps with safety planning. Tracks safety plan.
PC: Assists in identifying and evaluating psychiatric symptoms. May suggest additional assessment. Assists in safety planning as needed.
Typical Timeline, Week 1
BHP
: Visit 1–2
PCP
: Visit 1–2
Case example
31-year-old male, presents to his primary care doctor asking for “sleeping pills.” His PCP takes a history and finds out he has not been sleeping well for the last month, he has been struggling to get work and has missed a few days, he has difficulty concentrating, and his wife is frustrated because he has “just checked out.” His PCP suspects he may be experiencing depression. Mr. A's PCP introduces him to Collaborative Care and the idea that a team of providers will care for him and treat depression in the primary care clinic. That first day he meets his BHP/care manager, who starts a mental health assessment, including a safety evaluation. Mr. A's team makes sure he completes a depression measure (in this case, the PHQ-9) to measure his symptoms. Mr. A's BHP/care manager enters him into the clinic patient registry. Mr. A is also scheduled for a close follow-up appointment to make sure he quickly is engaged in care.
Differential diagnosis and identifying a provisional diagnosis
Rule out common contributing medical problems and substance-related conditions
Some medical conditions can cause, contribute to, or mimic symptoms of mental illness.
Medical conditions
: Identify possible medical symptoms that present as psychological symptoms. In general, lab tests are indicated only if there is concern about a particular medical diagnosis.
Substance-related conditions
: Consider that substance abuse, withdrawal, or intoxication may present as psychological symptoms.
Develop and refine the differential diagnosis as a Collaborative Care team
A good differential diagnosis is needed to inform decisions regarding evidence-based treatment for behavioral health disorders. Chief complaint, associated somatic and psychological symptoms, and current level of functional impairment related to any symptoms must be assessed. This information helps teams develop an informed provisional diagnosis, which leads to an appropriate integrated-care treatment plan. However, developing a differential diagnosis as a team differs from developing one as an individual clinician. Each team member has an important role in developing differential and provisional/working diagnoses. Table 1.1 illustrates key questions and team goals helpful in generating differential diagnosis.
Table 1.1 Generating a differential diagnosis
Question
Key team goals
Further assessment
Are presenting symptoms caused by a medical problem?
PCP should consider medical causes for all presenting problems. Other team members may also identify medical problems for the PCP to consider.
Refer back to PCP for any medical concerns. Acute concerns are referred for urgent evaluation as appropriate.
Is this distress or a mental health disorder?
Functional assessment helps differentiate life distress from a mental health disorder. All mental health disorders cause significant functional impairment as criteria for diagnosis.
A patient with psychological distress but no formal mental disorder may only need brief supportive engagement and treatment instead of ongoing care management.
Is there a mood disorder?
Depressed mood is a common presentation. The team must work together to differentiate unipolar depression from bipolar disorder. Screening for mania or mixed bipolar disorder symptoms is an important part of assessment of every patient presenting with depression.
The PHQ-9 is widely used to screen for depression and to monitor treatment response.
The CIDI-3 brief structured interview for bipolar disorder can be used to assess for bipolar disorder in patients with depression.
Depression alone → Major Depression chapterDepression + history concerning for bipolar disorder → Bipolar Disorder chapter
Is there an anxiety- or trauma-related disorder?
Anxiety symptoms, including somatic symptoms of anxiety restlessness or feeling of fast heart rate, are common presentations in primary care.
Generalized anxiety disorder (GAD): Have you been worrying excessively for greater than six months? Are you a worrier?
See Anxiety and Trauma Disorders chapter for additional assessment.
Panic disorder: Do you experience sudden attacks of anxiety or unexplained physical symptoms, such as rapid heartbeat, shortness of breath, or chest tightness?
Social anxiety disorder: Are you uncomfortable in or do you avoid social situations?
Post-traumatic stress disorder (PTSD): Do you have a history of trauma or abuse with nightmares and flashbacks?
Obsessive-compulsive disorder (OCD): Do you have any repetitive or intrusive thoughts or behaviors that bother you?
Is there a substance use disorder?
Asking about substance use and considering urine toxicology can be helpful to identify substance use disorders in primary care. Symptoms can be caused by intoxication or withdrawal from substances as well.
For alcohol: Use the Audit-C three-item measure
For other substances: “In the past year have you used an illegal drug or used a prescription medication such as a narcotic pain pill for nonmedical reasons or more often than prescribed?”
See Substance Use chapter for additional assessment.
Is the patient experiencing psychotic symptoms?
Patients may complain of depression or other negative schizophrenia symptoms such as loss of motivation or anhedonia. Active psychotic symptoms can range from patients reporting auditory hallucinations to subtle symptoms such as concrete or disorganized thinking. Delusional thoughts or ideas of reference (patients reading special meaning into common occurrences) or thought broadcasting
See Psychosis chapter for additional assessment.
(other people can hear the patient's thoughts) can occur and should be assessed for.
Is the psychosis recent in onset or chronic?
Are the symptoms changing or are they fairly stable over time?
Is there an acute safety concern?
This is a crucial step because suicidal thoughts can lead to a suicide attempt. Safety concerns require development of a safety plan.Common safety concerns: danger to self (suicidal ideation, domestic violence situations), danger to others, grave disability (inability to take care of self due to a mental health condition putting the individual at risk of serious harm).
Every clinic should have a clear active suicide protocol developed as part of implementation. Clearly defining whose role it is to manage acute safety concerns should be part of team building. (See online materials for additional information.)
Is there another mental health presentation?
If the patient has screened negative for all the above disorders but still presents with significant functional distress, consider screening for other common presentations, such as chronic pain, attention-deficit hyperactivity disorder (ADHD), or dysfunctional coping style.Consult with PC or refer for additional treatment as appropriate.
Pain can cause functional impairment. See Chronic Pain chapter for additional assessment.Patient presenting with inability to concentrate and/or focus as an isolated symptom or after other mental health comorbidity is treated could have ADHD. See ADHD chapter for additional assessment.The team is struggling with difficult patient interactions; see Challenging Clinical Situations chapter for additional assessment.
Assessment of comorbid psychiatric disorders and psychological difficulties
Many mental health problems are comorbid with both medical and other mental health diagnoses. Common co-occurring illnesses for each disorder are discussed in individual chapters. These are often identified as part of the differential diagnosis process and treatment planning.
Identifying a provisional diagnosis
The differential diagnosis process results in a provisional/working diagnosis (See Table 1.2). Team members may also identify comorbid medical or psychiatric disorders. This provisional diagnosis will inform recommendations for evidence-based treatment. All team members should understand the provisional diagnosis. Team members will learn additional clinical information about the patient, including observations of the patient, over time. Additional observations and information may lead to changes in diagnosis. Tracking a patient over time and adjusting diagnosis and treatment as needed is one of the strengths of Collaborative Care.
Table 1.2 Common conditions in primary care
Behavioral health care in primary care settings focuses on mental health problems commonly encountered in this setting. In each chapter common ICD10 codes will be listed here for easy reference.
Team goal: Generate differential diagnosis and establish provisional diagnosis
Team members share significant information to ensure treatment planning is patient-centered, appropriate, safe, and effective. Discover the mental health comorbidities that should be addressed as part of a comprehensive and effective treatment plan.
Working as a team
Patient: Describes health and mental health history. Works with PCP and BHP and follows through on recommended diagnostic testing; reports patterns of medication use and potential side effects; tracks and reports physical and social activities as recommended by the BHP.
PCP: Evaluates possible medical problems using diagnostic testing and medical consultation as appropriate. Considers common diagnoses and refers to BHP for additional assessment as needed. Continues to provide general medical care and prescribes medications for common mental health disorders as clinically indicated.
BHP: Conducts a thorough psychosocial assessment. Works with the PCP and PC to work through differential diagnoses to refine mental health treatment targets and plan.
PC: Expands medical and psychiatric differential diagnosis and recommends additional assessment as needed. Assists BHP in differential diagnosis.
Typical Timeline Week 1
BHP: Visit 1–2
PCP: Visit 1–2
Case example
Mr. A's team works together to develop a differential for his presenting symptoms of insomnia. The PCP generates an initial diagnosis of depression after excluding obvious medical comorbidity, such as sleep apnea. This diagnosis is further assessed by the BHP/care manager, who assesses for bipolar disorder, anxiety disorders, and substance use disorders, none of which are found. The BHP/care manager focuses on understanding current functional impairments and Mr. A's goals for treatment.
Collaborative Care treatment
Treatment in Collaborative Care can be broken down into three key phases: (a) initiation of treatment, (b) follow-up and treatment to target, and (c) completion of treatment and relapse prevention. Effective treatment strategies for the Collaborative Care team are reviewed in two chapters: Chapter 10, “Evidence-Based Psychopharmacology for the Collaborative Care Team,” and Chapter 11, “Evidence-Based Behavioral Interventions for the Collaborative Care Team.”
Initiate treatment plan
General approaches
Common treatment approaches are shared by the whole team. These strategies are often important in engaging the patient in treatment.
Patient education
All team members are comfortable in providing basic patient education. Teams can provide this information verbally or by using patient handouts. High-quality Web resources may also help. Having common resources that team members utilize can lead to providing consistent information for patients.
Examples of patient education include:
Information about the diagnosis and typical illness course
Treatment options available to patient, including pros and cons of options
Self-management strategies
How the team will work together to provide treatment
Roles of different team members
Expectations for participation in treatment
Setting treatment goals
A core feature of Collaborative Care is setting clearly understandable patient-centered goals supported by the whole team. These goals should be clearly noted in the patient's chart. Goals should have observable, measurable outcomes (i.e., behaviors).
Common strategies for setting Collaborative Care treatment goals:
Functional improvement: Which current symptoms interfere the most in the patient's life? What would the patient be doing if not experiencing symptoms? How will the patient and the team know if the treatment is effective?
Behaviorally defined and measurable: Goals should be concrete and specific. Goals must be informed by the patient's perspective. Make sure goals reflect what is of high priority for the patient. Be aware of setting goals the patient does not value or feels are impossible to reach.
Patients must participate in treatment goal development, and should “own” or at least “co-own” the treatment plan. The BHP makes sure the treatment team is patient-centered and advocates for crafting goals in ways that will be most engaging to the patient. If initial plans do not succeed, the BHP can help explore alternatives that are more likely to help the patient achieve his/her goals.
Consider using a standard measure to track progress: Tracking symptoms using standardized measures, such as the PHQ-9 for depression, can help the team measure both individual patient as well as aggregate population outcomes.
Using evidence-based treatment
Team members delivering Collaborative Care work together to provide high-quality evidence-based treatments. Because team members have different skills, patients can benefit from choosing from a range of evidence-based medication and behavioral interventions. Each chapter will highlight current evidence-based strategies for common mental health disorders.
In general, the PCP will initiate medication treatments if indicated and the BHP will focus on delivering behavioral or psychotherapeutic interventions. The psychiatric consultant should help guide the effective application of these interventions. Although each treatment section is divided up by these roles, all team members should be familiar with all treatments to reinforce treatment participation to the patient. For example, although medications will be prescribed by the PCP, the BHP will support medication adherence and may be the first person to hear about side effects. Conversely, although the BHP will set behavioral goals with the patient, a PCP checking in with the patient about these goals can reemphasize the importance of this part of the treatment plan.
Medications
: Each chapter will review current medication options for the specific disorder.
Chapter 11
will review general approaches to medication management in primary care and more detailed prescribing protocols for commonly used medications
Brief behavioral interventions
: Each chapter will review current behavioral interventions and, as available, adaptations for use in primary care settings.
Chapter 10
will give a general overview of delivery of brief behavioral interventions in primary care settings and overviews of key evidence-based psychotherapies.
Safety Planning
Safety planning is a team responsibility. Each team member will have a specific role in assessment, triage, and developing a safety plan defined by their organization. Team members should consider safety planning part of the patient-centered care delivered in a Collaborative Care model. Being supported in providing distressed patients with a safety plan is one benefit of working as part of a Collaborative Care team. Each Collaborative Care team will need to develop a protocol to manage safety concerns that is appropriate for the clinic setting and takes into account state laws and available resources. A sample protocol and safety plan is included in the online materials.
Team goal: Initial treatment planning
Create an initial treatment plan aligned with the patient's treatment goals and appropriate to the biopsychosocial assessment of the patient's unique presentation. The patient should have an initial understanding of the role of each clinician in the plan, a sense that all clinicians are working together and with him/her to help achieve the patient's goals, and a clear sense of how the plan addresses his/her concerns and goals.
Working as a team
Patient: Actively participates in exploring treatment options and formulating an initial treatment plan. Voices concerns about the treatment plan. Follows through on initial treatment recommendations, speaks up about issues and concerns as treatment progresses.
PCP: Establishes and maintains therapeutic alliance; educates the patient about components of the treatment plan, in particular the use of medications and other medical treatments; emphasizes the importance of addressing psychosocial contributors to depression and other problems, such as chronic pain and working closely with the BHP; sets and reviews medical treatment goals and monitors progress; prescribes and monitors medications; and makes medical referrals as needed.
BHP: Establishes and maintains therapeutic alliance; addresses crisis management and safety planning strategies; reviews the full treatment plan with the patient and addresses questions and concerns; provides brief behavioral interventions addressing comorbid mental health issues and promoting chronic pain self-management; facilitates communication between team members; and makes and supports referrals (e.g., disability, vocational rehab, social services, chemical dependency, additional psychotherapy).
PC: Resource for diagnosing and treating psychiatric comorbidities; informs treatment planning; supports safety planning; and medication and behavioral management recommendations.
Typical Timeline Week 1
BHP: Visit 1–2
PCP: Visit 1–2
PC: Available for initial case review.
Case example
Mr. A's main focus is on sleeping and he is interested in taking medications. Both the PCP and BHP/care manager feel that input from the psychiatric consultant would be helpful to find a good medication treatment. Mr. A's BHP/care manager discusses his case with the psychiatric consultant by presenting his case over the telephone and after obtaining a basic history, the psychiatric consultant recommends mirtazapine, an antidepressant that is mildly sedating. The PCP prescribes this medication and the BHP/care manager provides psychoeducation about this choice with a special emphasis on why this is a good choice for the patient goal of improving sleep and how depression treatment will also support this goal. The BHP/care manager again schedules close follow-up by telephone (to assess tolerability of the medication in a week) and a future visit in person in three weeks.
Follow-up and treatment adjustment to achieve treatment to target
Measurement-based practice
Principles of Collaborative Care include regular assessment of symptoms and progress toward clinical goals, as well as adjusting treatment to achieve treatment targets. Collaborative Care teams will schedule regular follow-up to track patient progress toward goals. This proactive approach to patient care often involves outreach to patients who do not attend scheduled follow-up visits. At each follow-up visit, patient response to treatment is assessed by both interview and standardized measures. This approach helps team members quickly identify patients needing treatment adjustments, so patients do not stay on ineffective treatments for too long.
PCP approaches
: Focus on common follow-up questions, important monitoring for common medications, common next steps.
BHP approaches
: Focus on common challenges encountered in brief behavioral interventions and how to address them. Also, patient engagement strategies discussed.
PC approach
: Will evaluate entire active caseload and work with BHP to provide case reviews for patients not improving as expected.
Stepped-care approach
A key principle of Collaborative Care treatment is that care is intensified or changed if patients are not responding to initial treatments. If patients are not achieving treatment goals, the treatment plan should be adjusted. This process is repeated until a patient demonstrates clinical improvement, or until resources in the clinic have been exhausted and a referral to more intensive treatment is needed. Sometimes this involves the psychiatric consultant providing additional case review, via in-person or televideo consultation, to help the team consider other evidence-based approaches.
Referring for additional services
: Some patients will need more intensive services than can be offered in primary care. Each chapter will review commonly used criteria for each disorder for when to increase level of care. These will be listed for the typical primary care situations, although availability of resources will vary depending on your practice setting.
Team goal: Be prepared to adjust the treatment plan until treatment targets are achieved
Adjust medications and behavioral treatments as appropriate to step up care. As patients become more engaged in treatment and move toward treatment goals, self-management strategies can begin, and comorbid psychiatric disorders can continue to be treated.
Working as a team
Patient: Participates as a partner in trying treatment strategies and communicates concerns with treatment.
PCP: Addresses therapeutic alliance concerns as needed; consults with the BHP as needed; follows through on medical treatment goals and outcomes of medical referrals as needed; continues to monitor progress; and adjusts prescriptions as needed.
BHP: Continues to address engagement, crisis management, and safety planning as needed. Steps up brief behavioral interventions as needed to address comorbid mental health issues or persistent mental health symptoms.
PC: Informs treatment planning; supports safety planning; advocates for stepping up care and altering medication recommendations as needed; and supports and suggests behavioral management recommendations.
Typical Timeline ∼6–12 months
BHP
: Every two weeks until completion of treatment.
PCP
: Every four to six weeks while adjusting medications, then less often.
PC
: Case review at least every eight weeks until improvement and more frequently if needed.
Case example
Mr. A reports having tolerated mirtazapine when contacted by phone a week after his initial appointment. He reports improved sleep but no change in depressed mood. The BHP/care manager provides reassuring psychoeducation that it was a good sign that he was tolerating the medication and experienced improved sleep. The BHP/care manager also explains that typical response for antidepressant treatment occurs at six to eight weeks. The BHP/care manager introduces the idea of patient activation and helps Mr. A set a goal to call one friend a week to reduce social isolation. Mr. A is reminded to attend his follow-up appointment. At his follow-up appointment, Mr. A reports a little less depression when his PHQ-9 behavioral rating scale is administered. His PCP decides to increase his dose to the middle of the dosing range as previously suggested by the psychiatric consultant note. The BHP/care manager continues to set goals for patient activation. This proactive treatment approach continues for eight weeks until patient has experienced a significant reduction in depression symptoms.
Completing treatment and relapse prevention
Caseload management
Typically, an active caseload in Collaborative Care will only include symptomatic patients. Managing the size of the active caseload will be important as BHPs have to meet with patients regularly and can only mange a specific size caseload at any one time. The decision to graduate a patient should be made as a team. Often the psychiatric consultant and the BHP will discuss patient progress as part of psychiatric consultation.
Completion of treatment
The concept of a defined treatment episode may be new to a treatment team, but it is an important concept for caseload management in Collaborative Care. Ideally, each patient completes treatment by accomplishing improvement in clinical symptoms and daily functioning. Sometimes patients may complete treatment by referral to outside resources.
Relapse prevention
As an episode of treatment ends, relapse prevention planning should be started. Relapse prevention is important for long-term sustainability of a patient's clinical improvement. The patient and the team should work together to identify the treatments and interventions that have supported improvement and the ways in which they can maintain these gains. Ideally this should involve the completion of a written relapse prevention plan (a sample is included in the online materials).
All team members should contribute to this plan:
PCP
: Will outline for the patient a medication plan and clear instructions to request reevaluation; frequency of follow-up for regular visits.
BHP
: Is primarily responsible for working with patient to complete relapse prevention plan. Will document this plan in medical record, and will identify warning signs and behavioral approaches to address these with the patient.
PC
: Will provide the patient with monitoring, guidance about medications, and clear instructions regarding when to request reevaluation.
Self-help books and Web resources: Each chapter has a section with books and websites to be used for further information and to share with patients as part of the psychoeducation delivered by the Collaborative Care team.
References: Each chapter lists a short bibliography of key papers and resources used to develop the content for the chapter. These may be interesting for members of the team who desire deeper knowledge about a key clinical area.
Team Goal: Relapse prevention
The relapse prevention plan should capture the key treatment strategies that the patient used to improve. This should include both medical and psychotherapeutic approaches that were helpful. The relapse prevention plan should also include recommendations for duration of medications treatment and symptoms to monitor, including when to represent to clinic if symptoms reappear.
Working as a team
Patient: Participates in establishing a relapse prevention plan with the BHP and the PCP; tracks the ongoing plan and reengages in additional care if symptoms or functional impairment significantly worsen.
PCP: Provides plan for ongoing medication management and clear instructions to the patient to request reevaluation if symptoms recur.
BHP
