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Collaborative care is a model of integrated care that was developed at the University of Washington AIMS Center to treat mental health conditions like depression and anxiety which require regular follow-up due to their persistent nature. Collaborative care focuses on defined populations that are tracked within a registry and leverages a care team made up of primary care providers, behavioral health care managers, and psychiatric consultants, who provide evidence-based, brief interventions and prescribe medication when necessary.

Over 90 randomized trials have proven collaborative care to be one of the most effective ways to treat diverse populations that have a variety of behavioral health and comorbid medical conditions, enhancing both mental and physical well-being.

Content Reference: https://aims.uw.edu/ & https://www.neuroflow.com/

Collaborative care requires new workflows and team members. In a typical medical care scenario, the treatment team has two members, the primary care provider (PCP) and the patient. In collaborative care, there are two additional roles, the behavioral health care manager (BHCM) and the psychiatric consult. These additional care team members are critical for closing the gap between physical and mental health care, ensuring behavioral health conditions are not left untreated as is often the case in primary care settings.

The primary care provider determines whether the patient should be enrolled in collaborative care based on behavioral health symptoms, medications needs, or the patient’s level of support. Treating behavioral health  conditions in a primary care setting improves access for patients who already have an existing relationship with their PCP. The PCP then introduces the patient to the BHCM who will conduct regular, brief interventions with the patients. These interventions include  conducting validated assessments like the PHQ-9 for depression or GAD-7 for anxiety as well evidence-based
therapies like cognitive-based therapy (CBT).

In addition to communicating with the PCP and patient regularly, the BHCM also works with a psychiatric consultant to determine prescription needs and adjust  he care plan based on patient outcomes. The care manager and psychiatric consult collaborate through a patient registry to effectively manage the patient caseload and monitor the population. This workflow makes it easier to identify, treat, and monitor patients who have behavioral health conditions within a primary care setting and drives significantly improved outcomes. In the groundbreaking IMPACT Study, collaborative care doubled the effectiveness of depression treatment for older adults in the primary care setting.

Content Reference: https://aims.uw.edu/ & https://www.neuroflow.com/

According to the University of Washington AIMS Center, there are five core components of the collaborative care model, and each element must be in place in order to deliver effective care to the patient population.

Patient-Centered Team Care
The patient must be at the center of the care team to deliver high-quality collaborative care. Providing both physical and mental health care through a single care team is comfortable and convenient for the patient and improves engagement. Greater patient engagement leads to a better health care experience and improved patient outcomes.

Population-Based Care
Collaborative care is delivered across a population to ensure no individual falls through the cracks. A patient registry enables care teams to track every patient in the population and identify when behavioral health conditions worsen and regular interventions are required.

Measurement-Based Treatment to Target
Also known as stepped care, measurement-based treatment to target means that patients have a specific goal or clinical outcome to reach through collaborative care, such as a score that’s 10 or lower on a PHQ-9 assessment. Treatment plans are measured against those results and change if a patient’s behavioral health is not improving.

Evidence-Based Care
Collaborative care provides treatments that are backed by credible research, including
evidence-based therapies like cognitive-based therapy (CBT) and problem-solving treatment
(PST). The care manager delivers these therapies in the form of brief interventions, taking the burden of care off the PCP.

Accountable Care
Collaborative care can be billed through a fee-for-service arrangement using CPT codes. CoCM is also compatible with a value-based care billing model. In that arrangement, providers are reimbursed for the quality of care and clinical outcomes, not just the volume of care provided.

CoCM programs are inherently patient-centric because they are proven to increase patient engagement by treating physical and behavioral health together. Providers empower patients to set goals for themselves and to make sure those goals are communicated to every member of the care team. For patients, goals should be about improving their lives—not just their diagnosis.
Patients work directly with their behavioral health care managers to set their personal goals so that clear communication is formed at the onset of the program. The care manager discusses the patient’s desires with the psychiatric consultant who then uses this information to provide patient-focused  recommendations to the medical provider. A patient-centric program should also provide behavioral health resources, such as digital health content, that patients can explore outside of a healthcare setting. Some collaborative care technology solutions offer patients tools to track their well-being or self-guided DCBT curricula. These collaborative care platforms provide diverse options for patients to manage their behavioral health in a way that works best for them.

Content Reference: https://aims.uw.edu/ & https://www.neuroflow.com/

Implementing collaborative care requires significant upfront investment of time and resources to establish new workflows, train staff, and invest in the technology necessary to manage population-wide data. The right technology can streamline workflows and create the necessary connections between an EHR and the patient registry so that no patient is overlooked.
Technology can also empower care teams to deliver assessments and treatment remotely to a much larger population and personalize care plans based on patient engagement and scores.

For example, a digital collaborative care solution can quickly identify an individual’s depression symptoms, flag that patient in the registry for the care team, and immediately deliver customized depression content so that the patient receives timely support. After a patient completes collaborative care, behavioral health technology can continue to engage that patient with evidence-based content and monitor well-being over time. This is incredibly valuable if a patient relapses in between primary care visits. When a patient’s well- being declines, the primary care provider is alerted immediately, and the patient receives the appropriate level of care before symptoms worsen.

Content Reference: https://aims.uw.edu/ & https://www.neuroflow.com/

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User can download the mobile Android or iOS Application to use the Healmed Application

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The University of Washington AIMS Center developed collaborative care as an integrated care model to address mental health conditions such as depression and anxiety. More than 90 randomized trials have demonstrated collaborative care’s effectiveness in treating diverse populations with a range of behavioral health and comorbid medical conditions, thereby improving both mental and physical well-being. Mental health conditions such as depression and anxiety conditions require regular follow-up due to their persistent nature. Collaborative care focuses on specific populations tracked within a registry and utilizes a care team consisting of primary care providers, behavioral health care managers, and psychiatric consultants. This team delivers evidence-based, brief interventions and prescribes medication as needed.

In a typical medical care scenario, the treatment team consists of the primary care provider (PCP) and the patient. However, the collaborative care model introduces two additional roles: the behavioral health care manager (BHCM) and the psychiatric consultant. These additional team members play a crucial role in bridging the gap between physical and mental health care, ensuring that behavioral health conditions are not overlooked, which often happens in primary care settings.

The primary care provider assesses whether the patient should participate in collaborative care, taking into account behavioral health symptoms, medication requirements, and the level of support needed. By addressing behavioral health conditions within the primary care setting, collaborative care improves accessibility for patients who already have an established relationship with their PCP. Subsequently, the PCP introduces the patient to the BHCM, who conducts regular brief interventions. These interventions encompass validated assessments such as the PHQ-9 for depression or GAD-7 for anxiety, as well as evidence-based therapies like cognitive-based therapy (CBT).

In addition to maintaining regular communication with the PCP and patient, the BHCM collaborates with a psychiatric consultant to determine medication needs and adjust the care plan based on patient outcomes. The care manager and psychiatric consultant work together using a patient registry to effectively manage the caseload and monitor the overall population. This workflow simplifies the identification, treatment, and monitoring of patients with behavioral health conditions within a primary care setting, leading to significantly improved outcomes.

There are five core components of the collaborative care model, and each element must be in place in order to deliver effective care to the patient population.
Patient-Centered Team Care
The patient must be at the center of the care team to deliver high-quality collaborative care. Providing both physical and mental health care through a single care team is comfortable and convenient for the patient and improves engagement. Greater patient engagement leads to a better health care experience and improved patient outcomes.

Population-Based Care:
Collaborative care is delivered across a population to ensure no individual falls through the cracks. A patient registry enables care teams to track every patient in the population and identify when behavioral health conditions worsen and regular interventions are required.

Measurement-Based Treatment to Target:
Also known as stepped care, measurement-based treatment to target means that patients have a specific goal or clinical outcome to reach through collaborative care, such as a score that’s 10 or lower on a PHQ-9 assessment. Treatment plans are measured against those results and change if a patient’s behavioral health is not improving.

Evidence-Based Care:
Collaborative care provides treatments that are backed by credible research, including evidence-based therapies like cognitive-based therapy (CBT) and problem-solving treatment (PST). The care manager delivers these therapies in the form of brief interventions, taking the burden of care off the PCP.

Accountable Care:
Collaborative care can be billed through a fee-for-service arrangement using CPT codes. CoCM is also compatible with a value-based care billing model. In that arrangement, providers are reimbursed for the quality of care and clinical outcomes, not just the volume of care provided.

CoCM programs prioritize the needs of patients as the focal point, as they have been proven to enhance patient engagement by addressing both physical and behavioral health. Providers empower patients by encouraging them to establish their own goals and ensuring that these goals are effectively communicated to every member of the care team. It is important for patients to focus on improving their overall lives rather than solely on their diagnosis.

During the program, patients collaborate directly with their behavioral health care managers to establish their individual goals, establishing clear communication from the start. The care manager then discusses the patient’s preferences with the psychiatric consultant, who utilizes this information to provide personalized recommendations to the medical provider.

The successful implementation of collaborative care necessitates a significant initial investment of time and resources to establish new workflows, train staff, and acquire the technology required for managing population-wide data.

Technology has the potential to empower care teams by enabling remote delivery of assessments and treatments to a larger population while personalizing care plans based on patient engagement and scores. For instance, our HealMed solution can rapidly identify symptoms of depression in an individual, highlight that patient in the registry for the care team’s attention, and promptly provide timely support via the care team. Even after the completion of collaborative care, behavioral health workflow can continue engaging the patient through scheduled assessments and monitor their well-being over time. This proves invaluable in case a patient experiences a relapse between primary care visits. If a patient’s well-being begins to deteriorate, the primary care provider is immediately alerted, ensuring that the patient receives the necessary level of care before symptoms worsen.