Sign up for alerts

Autumn 2007 | Vol 11 No 1

Focus

Collaborative care works

How to make it happen

By Roger Bland

Why do we need collaborative mental health care?

The family physician is the person most people go to when seeking help for any health problem, including a mental health or substance use problem. But family physicians may have issues with psychiatry and other mental health services. For example, family physicians can have difficulty making timely referrals or accessing specialized treatment services, and are often excluded from being part of the ongoing treatment of the patient. In general, they feel that specialized mental health services are not “in touch”with the realities of primary care practice. Collaborative mental health care provides a means of solving some of these problems and improving patient outcomes.

Collaborative care is what happens when health care providers work together in a formally integrated system to provide bettercoordinated services for patients. The health care providers come from different disciplines, but generally include firs contact and specialized service providers like physicians, nurses, nurse practitioners, social worker, occupational therapists, psychiatrists and psychologists.

According to the Canadian Collaborative Mental Health Initiative (see Collaboration sidebar), collaborative care can involve better communication, closer personal contacts, sharing of clinical care, joint educational programs and joint program and system planning.

Collaborative care emphasizes the role of primary care, which includes, but is not limited to, family physicians, since professionals like nurses and nurse practitioners also deliver some form of primary care. Primary care providers working in a collaborative program can offer their patients on-site access to specialized services and treatments without complex, frustrating and time-consuming waits. The support offered by the specialist to the primary care service provider enhances the latter’s role, and provides a more positive experience for the patient. Trust and confidence develop as a result of working together, and patients come to feel a better sense of participating in their own health care and recovery. Many patients can be managed effectively in these circumstances, with greater satisfaction for all concerned.

What works and what doesn’t?

The May 2006 issue of the Canadian Journal of Psychiatry features a review I conducted with Dr. Marilyn Craven called “Better Practices in Collaborative Mental Health Care: An Analysis of the Evidence Base.” The review of more than 900 articles found 38 studies that investigated the impact of collaborative mental health care using relatively strong research designs with experimental methodologies or outcome measures. Here’s what works:

Collaborative relationships require time, preparation and supportive structures. Successful collaborative care arrangements often grow out of pre-existing clinical relationships. Real change, particularly at the system level, takes time to be developed and may need to be introduced gradually in a stepwise fashion. One of the best studies built on pre-existing relationships in the primary care practice and resulted in high levels of collaboration and good patient outcomes. Positive staff attitudes and “buy-in” are also critical to achieving success.Moreover, these relationships may also require system changes and some reorganization of services. Two studies showed how a potentially good intervention could fail because of poor collaboration and poor implementation.

Co-location of services is important both for providers and clients. Effective collaboration between mental health specialists and primary care providers most often develops when clinicians are co-located and the location is familiar and non-stigmatizing for patients. Plainly put, providers need to meet face-to-face to engage in collaborative relationships. Offering patients mental health care within the primary care setting engages patients more fully and lowers “no show” rates. Likewise, the literature suggests that co-location of substance abuse treatment in primary care enhances outcomes.

The actual degree of collaboration does not always predict the clinical outcome. Although positive outcomes generally occur in collaborative programs with higher levels of collaboration, some services with low levels of collaboration also show positive outcomes.

For depression, pairing collaboration with treatment guidelines results in better outcomes than either intervention alone, and the benefits are greatest for the most severely depressed patients. (See Depression below) In many cases, patients with milder forms of depression tend to improve spontaneously. In fact, treatment protocols developed for more severe disorders may not be applicable to those with minor depression.

While some studies showing poor or mixed outcomes have also used treatment guidelines and protocols, it is likely that many of these are poorly implemented. Moreover, studies that use clinical guidelines and protocols, but that do not use a collaborative approach, do not show improvements in patient outcomes over standard care.

Including systematic patient follow-up in treatment protocol predicts good clinical outcome in collaboration studies for depression. Length of follow-up seems to be critical; two studies with follow-up of 12 months or longer showed increasing clinical benefit over time. These findings suggest that health services should be organized to incorporate routine systematic, long-term follow-up into the treatment protocol, rather than waiting for the patient to initiate contact when things are not going well. Patient follow-up is frequently delegated to another clinician or care manager, usually with stepped-approach mechanisms for changing the treatment when patients are not responding well.

Increased adherence to medication and better outcomes may result from collaborative arrangements between health professionals, often including practice nurses. Furthermore, at least one study reported positive patient outcomes, even though there was no improvement in medication adherence. The authors of that study speculate that the improved outcome was due to the increased emotional support provided by nurses during adherence monitoring.

Collaboration alone has not been shown to produce enhanced knowledge or skill transfer from the mental health team to the primary care team (apart from a single study demonstrating improved prescribing for depression). Where change has taken place, it has been accompanied by substantial service restructuring designed to support the changes.

Enhanced patient education about mental disorders and their treatment was a component of many studies with good outcomes. Patient education was usually done by a non-physician primary health care professional. Similarly, guided self-help was an element of many successful studies, suggesting that patients may be willing to devote time and effort toward their own recovery.

Respecting patient choices about treatment may be an important factor in the patient’s engagement in collaborative care. For instance, studies have shown that between one-quarter and two-thirds of depressed patients prefer to be treated with psychotherapy rather than medication. Moreover, treatment with (protocol-based) psychotherapy has been shown to result in sustained quality-of-life benefits, which were not found with medication.

When research protocols have been introduced using permanent staff, they were far more likely to be maintained after the study than those that involved new staff.

Dr. Roger Bland is professor emeritus and former chair of the Department of Psychiatry at the University of Alberta, and executive medical director for the Alberta Mental Health Board. He has been a member of the Collaborative Working Group on Shared Mental Health Care since its inception in 1998. Visit the group’s website at www.shared-care.ca.