Implementation of a Collaborative Care Model to Prevent Mental Illness

Andrea Wittenborn, PhDAmy Romain, MSWPrincipal Investigators:Andrea K. Wittenborn, Ph.D., Associate Professor of Human Development and Family Studies (MSU) and Amy Romain, MSW, Director of Behavioral Medicine, Sparrow/MSU Family Medicine Residency

There is a crisis in mental healthcare in the U.S. Mental health and substance use disorders are common and disabling, resulting in high healthcare costs, lost productivity, and early death. Due to limited access, a shortage of mental health providers and stigma, many patients are unable to get the care they need (Kaiser, 2014). Primary care providers are the defacto mental healthcare providers, with 70% of all primary care visits driven by psychological factors. However, primary care physicians (PCPs) often lack the resources to adequately care for these patients. It is not possible to address behavioral health needs in the typical 15 minute encounter, yet only 25% of patients in need of services currently gain access to specialty mental healthcare (Talen & Valeras, 2013). We must redesign primary care to integrate behavioral health care services and provide collaborative, whole-person care in order to respond to burgeoning mental healthcare needs, reduce health disparities, and improve health outcomes. The integrative or collaborative care model, which consists of adding behavioral health consultants (BHCs) and collaborative psychiatrist support to the primary care team, presents an innovative answer to the mental health crisis. Recent efficacy and effectiveness findings indicate that collaborative care models (e.g., IMPACT, DIAMOND, COMPASS): (1) Improve access to services, (2) Reduce the stigma of seeking mental health care, (3) Allow for holistic coordination of care, (4) Improve outcomes for mental health and comorbid disorders, (5) Reduce health care costs through the reduction of emergency room visits and hospitalization, (6) Improve patient and provider satisfaction, (7) Increase provider productivity, and (8) Facilitate early intervention and increase access to support services (Unützer, et al., 2002).

 Collaborative care facilitates improved population health through better care at lower costs and enhances the patient experience; outcomes that are consistent with the goals of the Institute for Healthcare Improvement Triple Aim. In line with the Quadruple Aim (which includes enhanced provider well-being), these inter-professional partnerships have been shown to increase provider satisfaction, engagement and reduce burnout. The integration of behavioral health services is mandated by the National Committee for Quality Assurance 2014 standards for the Patient-Centered Medical Home, promoted by forward-looking health plans, and encouraged by Health Resources and Services Administration, and Substance Abuse and Mental Health Services Administration. Thus, there is an urgent need to implement and evaluate a collaborative care model in primary care at Sparrow to prevent mental illness.

 Most prior studies of collaborative care focus on managing disorders; our protocol will be unique in its focus on preventing them. About 75% of U.S. health care dollars are spent treating conditions that are preventable, yet preventive care represents only 3% of U.S. health expenditures (IOM, 2012). When the Affordable Care Act passed in 2010, it expanded coverage for behavioral health and preventive care, yet the expansion of preventive services has been slow (Garfield et al, 2011). Collaborative care models offer a solution to this critical need. 

 Patients with a history of adverse childhood experiences are in significant need of preventive care. The landmark Adverse Childhood Experiences (ACE) study (Felitti, et al., 1998), and the subsequent body of research on ACEs, provides unequivocal support for the negative consequences of childhood trauma and toxic stress. Results from the ACEs study reveal the multifaceted effects of childhood trauma and toxic stress on brain development, mental health and behavior, social functioning, health outcomes and a shortened life expectancy. Surprisingly, intervention in this area has been slow to develop. Yet, this is a perfect fit for collaborative care. We plan to implement a protocol for routine ACE screening and intervention focused on patient education, bolstering protective factors and connecting families with needed resources in effort to mitigate risks associated with elevated ACE scores. Screening and intervention will be targeted to (1) children, (2) adolescents, and (3) obstetric patients/expecting parents. 

 We aim to use the Adverse Childhood Experiences Questionnaire (ACE-Q; Dube, et al., 2003) to screen for adverse childhood experiences during specific well child visits or when concerns warrant further evaluation. In addition to screening for a history of trauma or toxic stress, the ACE-Q measures resiliency, an important protective factor in overcoming some of the risks associated with early childhood adversity. Because ACEs tend to cluster with their effects passed on from generation to generation, screening is directed at the parents/caregivers of young children. Though the focus is on the childhood experiences of the parents/caregivers, education about risk factors and the impact to toxic stress across the life span is relevant to the health and well-being of the whole family. Additionally, intervention with the BHC will focus on helping parents/caregivers develop skills, access resources, and build resilience in effort to mitigate these lifetime risks. The ACE-Q will also be administered to adolescent patients at defined intervals during well visits or when concerns warrant further evaluation. In these cases, the focus of the screening is on the adolescent’s childhood experience. BHC intervention will include education about risk factors and protective factors, brief counseling, resource linkage and a focus on helping teens build resilience. The third population targeted for ACE-Q screening is obstetric patients. The screen will be administered to the expectant mother during a routine OB visit. When possible, the screen will also be offered to her partner. Similar to our intervention with children, the focus of ACE work with expectant parents is to raise awareness of the lifetime risk factors associated with childhood adversity, identify risk factors and provide interventions aimed at bolstering resilience in these populations. 

 Our study will be guided by the implementation model RE-AIM (Glasgow, Vogt & Boles, 1999). While there are about 100 existing implementation models, RE-AIM is among the most highly cited and is used frequently in NIH research. RE-AIM, which stands for reach, efficacy, adoption, implementation, and maintenance, emphasizes the need for making context-based adaptations during the implementation process to increase the likelihood that the program will be maintained over time. Based on this framework, we will measure the number of patients screened and the percentage of the population identified as high risk (≥ 4) (reach), track the efficacy of interventions of BHC and change in patient resiliency scores over time (efficacy), assess staff attitudes about adopting the protocol, including potential barriers among office staff, nursing staff, residents, and attending physicians (adoption), assess individual- and program-level effects on outcomes (implementation), and measure the extent to which the program is maintained over time (maintenance).

 Relevance to the Center for Innovation and Research. This project aims to improve the quality of patient screening and referral, which is expected to result in improved detection of risk and prevention of illness, thereby reducing overall costs of disease.

 Relevance to Sparrow Health System. The 2016 Sparrow Community Health Needs Assessment identified a significant gap in behavioral health services, and identified mental health care as one of three major priorities. This project contributes to improving behavioral health care at Sparrow by implementing and supporting the maintenance of a collaborative care model to prevent the onset of mental illness by detecting and intervening upon risk factors related to adverse childhood experiences.

 Agency and FOA. In October 2017, we will submit an R34 application to NIH/NIMH in response to RFA-MH-16-410, Pilot Effectiveness Trials for Treatment, Preventive and Services Interventions. The funding announcement developed out of the new NIMH clinical trials pipeline initiative and specifically supports implementation science projects. We will request a budget of $450,000 over two years. Upon successful completion of the R34, we intend to submit an R01 to the companion announcement RFA-MH-17-608.