Should mental health interventions be locally grown or factory-farmed?

Remote Collaborative Care with Off-Site Behavioral Health Care Managers: A Systematic Review of Clinical Trials

BACKGROUND

In the United States, the majority of patients who require behavioral health care do not receive it due to an overall shortage of behavioral health specialists. The Collaborative Care Model (CoCM) is a team-based, highly-coordinated approach to treating common mental health conditions in primary care that has a robust evidence base. Several recent randomized controlled trials (RCTs) have demonstrated the effectiveness of remote CoCM teams. As telehealth technology and uptake expands, understanding the evidence for remote CoCM becomes increasingly crucial to inform CoCM practice and implementation.

OBJECTIVE

To systematically review RCTs regarding the effectiveness of remote CoCM teams in treating common psychiatric conditions in primary care and medical settings.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to structure our review. Our search strategy and development of search terms was informed by knowledge and review of the CoCM literature. Articles were reviewed by three authors and once selected, sent to two authors for further data extraction to describe various study characteristics and process measures relating to remote CoCM.

RESULTS

The literature search identified 13,211 articles, nine of which met inclusion criteria. The nine studies collectively demonstrate effectiveness of remote CoCM in treating a range of behavioral health conditions [(depression (n=7), anxiety (n=2), and PTSD (n=1)], across various populations and settings. Sample sizes ranged from 191 patients to 704 patients, publication dates from 2004 to 2018, and studies were conducted from 2000 to 2014. Various process measures were also reported.

CONCLUSIONS

As the nine studies included in our systematic review demonstrate, remote CoCM can be effective in treating a range of behavioral health conditions in various primary care and specialty medical settings. These findings suggest organizations may have more flexibility in building their CoCM team and drawing upon wider workforces than previously recognized. As recent shifts in telehealth policy and practice continue to motivate telehealth approaches, further research that can inform best practices for remote CoCM will be useful and valuable to those making organizational decisions when implementing integrated care models.

Cost-Effectiveness of Collaborative Care for Depression in HIV Clinics

OBJECTIVE

To examine the cost-effectiveness of the HIV Translating Initiatives for Depression Into Effective Solutions (HITIDES) intervention.

DESIGN

Randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care.

SETTING

Three Veterans Health Administration HIV clinics in the Southern United States.

SUBJECTS

Two hundred forty-nine HIV-infected patients completed the baseline interview; 123 were randomized to the intervention and 126 to usual care.

INTERVENTION

HITIDES consisted of an offsite HIV depression care team that delivered up to 12 months of collaborative care. The intervention used a stepped-care model for depression treatment, and specific recommendations were based on the Texas Medication Algorithm Project and the VA/Department of Defense Depression Treatment Guidelines.

MAIN OUTCOME MEASURES

Quality-adjusted life years (QALYs) were calculated using the 12-Item Short Form Health Survey, the Quality of Well Being Scale, and by converting depression-free days to QALYs. The base case analysis used outpatient, pharmacy, patient, and intervention costs. Cost-effectiveness was calculated using incremental cost-effectiveness ratios (ICERs) and net health benefit. ICER distributions were generated using nonparametric bootstrap with replacement sampling.

RESULTS

The HITIDES intervention was more effective and cost saving compared with usual care in 78% of bootstrapped samples. The intervention net health benefit was positive and therefore deemed cost-effective using an ICER threshold of $50,000/QALY.

CONCLUSIONS

In HIV clinic settings, this intervention was more effective and cost saving compared with usual care. Implementation of offsite depression collaborative care programs in specialty care settings may be a strategy that not only improves outcomes for patients but also maximizes the efficient use of limited health care resources.

Cost-effectiveness of on-site versus off-site collaborative care for depression in rural FQHCs

OBJECTIVE

Collaborative care for depression in primary care settings is effective and cost-effective. However, there is minimal evidence to support the choice of on-site versus off-site models. This study examined the cost-effectiveness of on-site practice-based collaborative care (PBCC) versus off-site telemedicine-based collaborative care (TBCC) for depression in federally qualified health centers (FQHCs).

METHODS

In a multisite, randomized, pragmatic comparative cost-effectiveness trial, 19,285 patients were screened for depression, 2,863 (14.8%) screened positive, and 364 were enrolled. Telephone interview data were collected at baseline and at six, 12, and 18 months. Base case analysis used Arkansas FQHC health care costs, and secondary analysis used national cost estimates. Effectiveness measures were depression-free days and quality-adjusted life years (QALYs) derived from depression-free days, the 12-Item Short-Form Survey, and the Quality of Well-Being (QWB) Scale. Nonparametric bootstrap with replacement methods were used to generate an empirical joint distribution of incremental costs and QALYs and acceptability curves.

RESULTS

The TBCC intervention resulted in more depression-free days and QALYs but at a greater cost than the PBCC intervention. The disease-specific (depression-free day) and generic (QALY) incremental cost-effectiveness ratios (ICERs) were below their respective ICER thresholds for implementation, suggesting that the TBCC intervention was more cost effective than the PBCC intervention.

CONCLUSIONS

These results support the cost-effectiveness of TBCC in medically underserved primary care settings. Information about whether to insource (make) or outsource (buy) depression care management is important, given the current interest in patient-centered medical homes, value-based purchasing, and bundled payments for depression care.

Mental health collaborative care and its role in primary care settings

Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.