Collaborative Care Models & Strategies
Taking on mental health care as an expansion of the primary care scope of practice is a challenging task. Pediatricians or practices vary in their levels of motivation to embrace mental health care. Incorporating mental health care into pediatric practice involves cycles of learning, consultation, and practice. The process usually starts small, often with a few champions who take on straightforward cases, and moves outward in numbers of clinicians and types of cases.
A key element of this process is consultation with a mental health specialist. Consultative relationships between mental health and primary care have evolved in various models, dictated in part by clinician preference, geography, and economics.
Expanding scope of practice to include basic mental health care
There are a variety of strategies and resources available for pediatricians who wish to expand their scope of practice to address common mental health conditions. Each clinician or practice must decide what type of collaborative or consultative relationship they want to develop with a mental health specialist.
If your practice wishes to implement a collaborative care model, the following steps may be helpful.
Assess your practice: Perform an assessment of your current practice, with close examination of current resources and provider interest in collaborative mental health care.
Identify champions: A physician champion serves as a leader of the collaborative care initiative within the practice and encourages other physicians to participate in the model. The physician champion takes the lead in trouble-shooting the model and seeking out information when needed.
Whom and what do you want to treat? Consider the current needs of your patient population and the mental health diagnoses you encounter frequently in practice. Identify a condition (for instance, ADHD or anxiety) and an age range (pre-adolescents) and develop skills and comfort in treating this condition. Over time, your scope of mental health care practice will likely expand.
Training: Identify the training needs of clinicians and support staff. Clinicians will need an introduction to mental health care and the diagnosis and treatment of the conditions they wish to target. Nursing staff will need the skills to inquire about mental health symptoms and treatment. Front desk staff must feel comfortable acknowledging and addressing mental health concerns as reasons for visits. If you are adopting a formal collaborative care program, the care manager will require training in maintaining a registry and tracking patient outcomes.
Toolkit: Assemble the standardized elements your practice needs to provide evidence-based care effectively and efficiently. Toolkits may include:
- brief diagnostic summaries and treatment algorithms
- screening tools and rating scales to track response to treatment
- patient educational material for patients and families, including overviews of the disorders, brief strategies for managing symptoms, medication information, and online references
- electronic record short-cuts to guide documentation of the visit, medication recommendations, patient advice for the after-visit summary, safety planning, and 504 plan requests
Screening and monitoring response to treatment:
Screening is an essential element of population-based care. Further consideration is found in the screening section.
Many, but not all, screening instruments are also appropriate for monitoring care and quantifying response to treatment.
Consultation model: Be clear about roles. Create a communication protocol.
- When is the consultant available (days and hours) and through what method of communication?
- What will the consultation include and not include?
- Will the consultant document in the patient record?
Referral base: The practice should consider its referral base of psychotherapy providers and what staff will assist with the referral process.
Billing: Review the practice’s billing policies and how collaborative mental health care can be incorporated into billing practices. Review your state’s laws regarding billing for mental screening and for collaboration.
Outcomes measurements in pediatric mental health care: Expanding scope of practice to include mental health care may not be cost-efficient, especially early on when visits take more time. A recent cost-effectiveness model of collaborative care for adolescent depression showed decreased cost and improved quality of life in the treatment group (Wright et al 2016). Value-based care contracts increasingly include incentives for mental health care quality metrics. Practice networks may find that they are able to decrease leakage when referring less to out-of-network mental health specialists.
Models of Mental Health Consultation and Collaboration
Telephone consultation lines: Many states are currently served by a mental health telephone consultation line through which primary care clinicians can review cases and seek advice on diagnosis and treatment in real time. These services are commonly based in academic centers and have state or federal government support.
Online learning collaboratives with case-based guidance: Project ECHO was developed at the University of New Mexico to facilitate access to specialty care in primary care settings. Project Echo is grounded in a ‘telementoring’ model, in which the participating clinician receives guidance from specialists while maintaining responsibility for managing the patient. In the ECHO mental health program, primary care physicians and care coordinators receive education and training, and have access to the ECHO team psychiatrist, psychologist, and addiction specialist for consultation and treatment questions.
Co-located care: Some pediatric practices opt to bring a mental health specialist (a clinical social worker, psychologist, or psychiatrist) under their roof, facilitating access to care. Co-location is not synonymous with co-management or even with communication, and practices vary in the extent to which they may share an electronic record, track progress, or maintain involvement in the mental health care of patients referred to their co-located colleagues.
Collaborative care: In this model, developed in adult primary care clinics at the University of Washington, the primary care provider (PCP) directs the treatment team and is responsible for identification and treatment of patients. The PCP provides patient care including prescribing psychiatric medications. The PCP is supported by a behavioral health care coordinator who provides psychoeducation, maintains a registry to track patient progress, and in some settings provides brief therapy. A psychiatrist reviews the registry with the care coordinator and provides direct and indirect (through the care coordinator) consultation to the PCP.
Core principles of collaborative care include evidence-based, patient centered care, population-based care, and measurement-based treatment to target. Population-based care is a strategy of identifying a set of patients in a clinical population with a treatable condition and making practice-level to improve that condition in all identified patients. Measurement-based treatment to target requires that the severity of the treatable condition can be measured, and that the practice goal is to move patients to remission on that measure. The patient registry is essential to managing measurement-based treatment for the clinical population.
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