Coordinating care to improve mental health
Collaborative Care is a team-based care model that provides comprehensive support to patients facing mental health challenges.
Patients often seek initial mental health support during primary care visits, where 40 to 60% of mental health treatment occurs and almost 70% of antidepressant prescriptions are written.
Consequently, primary care visits represent an important opportunity to connect with patients and coordinate mental health care.
How it works
In the Collaborative Care model, health care professionals from different disciplines work as a team in managing a patient’s care. This helps ensure that care is comprehensive, coordinated, and culturally sensitive.
This is particularly important for communities of color and marginalized groups who have historically faced barriers to accessing health care. In this model, a behavioral health care manager coordinates a patient’s treatment with their primary care clinician and a consulting psychiatrist from specialty mental health.
The care manager’s duties include managing medications in consultation with the prescribing physician and providing the patient with brief behavioral health interventions, such as behavioral activation or problemsolving treatment.
The care manager meets with the patient several times a month and is responsible for monitoring the patient’s progress and recommending any additional interventions. As treatment progresses, all members of the team share access to the patient’s care and treatment plans.
Is it effective?
The evidence base for Collaborative Care is well-established. Over 90 randomized controlled trials, several of which Kaiser Permanente participated in, demonstrate that it is as or more effective than traditional care models. It also uses fewer specialized mental health resources.
Furthermore, in treating depression, studies show it was twice as effective as standard care. Collaborative Care is also critical to health equity as it can alleviate disparities between white populations and communities of color (Black, Latino, Asian, and American Indian or Alaska Native persons).
Kaiser Permanente aims for all adult members with moderate to moderately severe depression and anxiety to have the option to obtain treatment through the Collaborative Care model.
5 essential components of Collaborative Care:
- Patient-centered team-based care: A care manager coordinates a patient’s treatment with their primary care clinician and a consulting psychiatrist from specialty mental health. They also provide interventions and monitor the patient’s progress. As treatment progresses, all members of the team share access to the care and treatment plans.
- Population-based care: Patient engagement and progress are tracked in a registry by the care team.
- Measurement-based care: Patient-reported data play a vital role in this approach. They are used to set goals, track progress, and achieve targeted health outcomes.
- Evidence-based care: Patients are offered treatments to address their condition, including medications and brief behavioral interventions.
- Accountable care: Program monitoring and continuous process improvement ensure that the program remains accountable to the evidence-based model. Kaiser Permanente markets1 determine what metrics are most useful and inform what is collected and tracked nationally.
1 Kaiser Permanente markets include California, Hawaii, Washington, Oregon, Colorado, Georgia, Maryland, Virginia, and Washington, DC.