The Learning Curve After Implementation of Collaborative Care in a State Mental Health Integration Program

The effects of behavioral health integration in Medicaid managed care on access to mental health and primary care services-Evidence from early adopters

OBJECTIVE

To evaluate the impacts of a transition to an "integrated managed care" model, wherein Medicaid managed care organizations moved from a "carve-out" model to a "carve-in" model integrating the financing of behavioral and physical health care.

DATA SOURCES/STUDY SETTING

Medicaid claims data from Washington State, 2014-2019, supplemented with structured interviews with key stakeholders.

STUDY DESIGN

This mixed-methods study used difference-in-differences models to compare changes in two counties that transitioned to financial integration in 2016 to 10 comparison counties maintaining carve-out models, combined with qualitative analyses of 15 key informant interviews. Quantitative outcomes included binary measures of access to outpatient mental health care, primary care, the emergency department (ED), and inpatient care for mental health conditions.

DATA COLLECTION

Medicaid claims were collected administratively, and interviews were recorded, transcribed, and analyzed using a thematic analysis approach.

PRINCIPAL FINDINGS

The transition to financially integrated care was initially disruptive for behavioral health providers and was associated with a temporary decline in access to outpatient mental health services among enrollees with serious mental illness (SMI), but there were no statistically significant or sustained differences after the first year. Enrollees with SMI also experienced a slight increase in access to primary care (1.8%, 95% CI 1.0%-2.6%), but no sustained statistically significant changes in the use of ED or inpatient services for mental health care. The transition to financially integrated care had relatively little impact on primary care providers, with few changes for enrollees with mild, moderate, or no mental illness.

CONCLUSIONS

Financial integration of behavioral and physical health in Medicaid managed care did not appear to drive clinical transformation and was disruptive to behavioral health providers. States moving towards "carve-in" models may need to incorporate support for practice transformation or financial incentives to achieve the benefits of coordinated mental and physical health care.

Implementation Barriers and Experiences of Eligible Patients Who Failed to Enroll in Collaborative Care for Depression and Anxiety

BACKGROUND

Effective and efficient implementation of the Collaborative Care Model (CoCM) for depression and anxiety is imperative for program success. Studies examining barriers to implementation often omit patient perspectives.

OBJECTIVES

To explore experiences and attitudes of eligible patients referred to CoCM who declined participation or were unable to be reached, and identify implementation barriers to inform strategies.

DESIGN

Convergent mixed-methods study with a survey and interview.

PARTICIPANTS

Primary care patients at an academic medical center who were referred to a CoCM program for anxiety and depression by their primary care clinician (PCC) but declined participation or were unable to be reached by the behavioral health care manager to initiate care (n = 80). Interviews were conducted with 45 survey respondents.

MAIN MEASURES

Survey of patients' referral experiences and behavioral health preferences as they related to failing to enroll in the program. Interview questions were developed using the Consolidated Framework for Implementation Research version 2.0 (CFIR 2.0) to identify implementation barriers to enrollment.

KEY RESULTS

Survey results found that patients were uncertain about insurance coverage, did not understand the program, and felt services were not necessary. Referred patients who declined participation were concerned about how their mental health information would be used and preferred treatment without medication. Men agreed more that they did not need services. Qualitative results exhibited a variety of implementation determinants (n = 23) across the five CFIR 2.0 domains. Barriers included mental health stigma, perceiving behavioral health as outside of primary care practice guidelines, short or infrequent primary care appointments, prioritizing physical health over mental health, receiving inaccurate program information, low motivation to engage, and a less established relationship with their PCC.

CONCLUSIONS

Multiple barriers to enrollment led to failing to link patients to care, which can inform implementation strategies to address the patient-reported experiences and concerns.

Adaptation of the collaborative care model to integrate behavioral health care into a low-barrier HIV clinic

Background

The collaborative care management (CoCM) model is an evidence-based intervention for integrating behavioral health care into nonpsychiatric settings. CoCM has been extensively studied in primary care clinics, but implementation in nonconventional clinics, such as those tailored to provide care for high-need, complex patients, has not been well described.

Method

We adapted CoCM for a low-barrier HIV clinic that provides walk-in medical care for a patient population with high levels of mental illness, substance use, and housing instability. The Exploration, Preparation, Implementation, and Sustainment model guided implementation activities and support through the phases of implementing CoCM. The Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions guided our documentation of adaptations to process-of-care elements and structural elements of CoCM. We used a multicomponent strategy to implement the adapted CoCM model. In this article, we describe our experience through the first 6 months of implementation.

Results

The key contextual factors necessitating adaptation of the CoCM model were the clinic team structure, lack of scheduled appointments, high complexity of the patient population, and time constraints with competing priorities for patient care, all of which required substantial flexibility in the model. The process-of-care elements were adapted to improve the fit of the intervention with the context, but the core structural elements of CoCM were maintained.

Conclusions

The CoCM model can be adapted for a setting that requires more flexibility than the usual primary care clinic while maintaining the core elements of the intervention.

Psychiatry's Expanded Integration into Primary Care

Integrated behavioral care, and in particular, the collaborative care model, has been working to improve access and treatment for people with mental health disorders. Integrated care allows for adaptable, scalable, and sustainable practice that addresses the mental health needs of the public. During the pandemic several challenges emerged to delivering integrated care. This disruption happened at a systems level, team-based care level, scope of care level, and patient access level. This article looks through the lens of those various levels to identify and some of the lessons learned to help build a more resilient and flexible integrated care program.

Telepsychiatric Consultation as a Training and Workforce Development Strategy for Rural Primary Care

PURPOSE

There is a shortage of rural primary care personnel with expertise in team care for patients with common mental disorders. Building the workforce for this population is a national priority. We investigated the feasibility of regular systematic case reviews through telepsychiatric consultation, within collaborative care for depression, as a continuous training and workforce development strategy in rural clinics.

METHODS

We developed and pilot-tested a qualitative interview guide based on a conceptual model of training and learning. We conducted individual semistructured interviews in 2018 with diverse clinical and nonclinical staff at 3 rural primary care sites in Washington state that used ongoing collaborative care and telepsychiatric consultation. Two qualitative researchers independently analyzed transcripts with iterative input from other research team members.

RESULTS

A total of 17 clinical, support, and administrative staff completed interviews. Participants' feedback supported the view that telepsychiatric case review-based consultation enhanced skills of diverse clinical team members over time, even those who had not directly participated in case reviews. All interviewees identified specific ways in which the consultations improved their capacity to identify and treat psychiatric disorders. Perceived benefits in implementation and sustainability included fidelity of the care process, team resilience despite member turnover, and enhanced capacity to use quality improvement methods.

CONCLUSIONS

Weekly systematic case reviews using telepsychiatric consultation served both as a model for patient care and as a training and workforce development strategy in rural primary care sites delivering collaborative care. These are important benefits to consider in implementing the collaborative care model of behavioral health integration.