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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

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.

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.

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
Accountable Practice	Quality Improvement Approach		Chapter 1

Integrated
Care

Creating Effective Mental
and Primary Health Care
Teams