Collaborative care models have proven to improve outcomes and access to mental health care

Jul 23 2018

Mental health has been in the news recently for all the wrong reasons, from unexpected celebrity suicides to a reported increase in depression diagnoses. Additionally, a recent CDC report found that the suicide rate has increased by 30 percent since 1999-;and 90 percent of the people who commit suicide have a preexisting psychiatric condition.

While there are many effective ways to treat mental health conditions, most people do not receive adequate care due to an associated stigma with mental health treatment and the functional impairment from mental health symptoms, such as the sense of hopelessness and lack of motivation that coexist with depression. Conversations around mental health are very different than the way many might talk about or even track other physical illnesses such as diabetes or the flu.

"One of the issues that we are grappling with in this country and in many places all over the world is that not everyone who needs attention gets attention -; or even knows that he or she needs psychiatric care," said Maria A. Oquendo, MD, PhD, chair of Psychiatry at Penn Medicine, whose department is partnering with experts in primary care to offer a unique service that hopes to combat these issues.

The initiative, called Collaborative Care Behavioral Health (CCBH), launched in January, and in just six months has already made a significant impact that program leaders say drives home just how surprisingly rampant the need for mental health services is. Its goal is to catch previously untreated mental health issues through a relationship that already exists-;the primary care physician.

CCBH puts licensed clinical social workers (LCSWs) specially trained in mental health care into primary care offices. So far five LCSWs work in eight Penn Medicine primary care practices in West Philadelphia and Center City and are available to over 100,000 patients. These experts work with a primary care provider and a psychiatrist to assess and treat patients as needed during their primary care appointments. Services range from screening for depression to supporting those who are struggling with addiction. Furthermore, if a patient is in acute distress or has a safety concern, such as suicidal thoughts or impulsive behavior, a physician will facilitate a warm handoff -; a real-time transfer of care -; to the LCSW for assessment, risk-stratification, and referral to the appropriate level of care.

The program also works to proactively identify patients who are high risk or who may benefit from enrollment in CCBH due to comorbid medical and psychiatric issues. This population-health strategy emphasizes prevention and access to ensure that patients' suffering is addressed early and often.

In addition to the collaboration between primary care physicians and the LCSWs in each office, the program is a piece of a larger data-driven network that connects these experts to case managers who support each patient by assisting with follow-up assessments, scheduling appointments, and following up to ensure patients are engaged with their care. The system also incorporates measurement tools to track quality, treatment, and accountability metrics -; such as timeliness of access to care, symptom remission, and use of the emergency room.

"The technology we're using allows us to track, treat, and continue engagement with these patients throughout their care," said Matthew Press, MD, MSc, associate medical director of the Penn Medicine Primary Care Service Line. "Just as physicians would follow and track blood sugar levels with a diabetic patient, you can track depression levels through this program. Many patients who are at risk for depression are not proactive about it, but this system allows us to catch patients at an early stage and aims to affect medical outcomes early on."

When the program first launched, the team expected to see about 500 patients in the first year. About six months in, there have been over 3,000 patients referred. To date, CCBH has been able to help almost 300 patients with PTSD, more than 210 who were suicidal, about 100 with addiction, more than 85 with active psychosis, and 65 with mania.

"These numbers show a huge, previously unknown and pent-up demand for treatment," said Cecilia Livesey, MD, medical director of strategy and integration for the department of Psychiatry. "We're not only surprised by these numbers, but also the severity of illness we're seeing. For example, at the beginning of this initiative, we estimated that a majority of patients seen through this program would have mild depression or anxiety. So far, the rates are much higher with average scores showing moderate depression."

The numbers show just how much a program like this can improve care by integrating medical and mental health care. And this experience is not unique to the City of Brotherly Love.

Collaborative care models have proven to be successful across the Unites States. The model has been shown to control costs, improve access to mental health care, improve clinical outcomes, and increase patient satisfaction in a variety of primary care settings – rural, urban, and among veterans. Collaborative care is also known to increase response to mental health and substance use treatments by 60 percent.

"Even though we're just six months in, we're showing that a collaborative care program is a win-win-win. There are better patient outcomes, improved patient and provider satisfaction, and reductions in health care costs," Livesey said. "But at the end of the day, what matters most is that patients who might have never had mental health support before are getting the care they need."