Experiences in Implementing Collaborative Care

Wagner’s Chronic Care Modelof disease management applied to the treatment of mental disorders in primary care has come to be known as integrated health care or collaborative care. The model is a systematic approach that involves integration of patient oversight by mental health specialists, care managers, and primary care physicians to proactively treat mental health disorders. That systematic integration of various disciplines moves team practices beyond parallel relationships to an interdisciplinary practice model that includes collaborative communication, collective action, a process orientation, and working together for common goals that are centered on whole-person care.

Our recent qualitative case study of an integrated health care model of service delivery for the treatment of depression in a low-income, uninsured adult population explored how a collaborative care model of service delivery works. We examined a single, interdisciplinary team of providers to explore how the integrated health care model of collaborative care was an effective strategy for providing mental health treatment to a predominantly Hispanic patient population at one grant-funded primary care safety-net clinic.

There is little doubt that the mental health treatment community has historically played a role in obstructing communication between providers, in the interest of protecting patients and advocating for privacy as it related to mental health diagnoses. However, despite common protests among professionals about private health information and the sharing of mental health records, in our study, the care manager expressed surprise at never meeting a patient who was concerned about who might gain knowledge about his or her mental disorder. In fact, she summarized, “They felt like, ‘I’ve got this team of people around me that care about me, that are all communicating.’ It’s like being a well-loved child.”

Another historical obstacle to collaboration between providers has been the influence of the traditional medical model, in which the primary care doctor maintains control of patient care and struggles with sharing responsibility, except to hand off care to a psychiatrist. Skepticism that collaborative care will create more work for the primary care physician is a common reaction to the implementation of the collaborative care model. In our clinic, we took several steps to combat resistance. A respected, experienced physician was asked to champion the model to skeptical physicians, and then the clinical social worker who was acting as care manager shadowed physicians during patient visits to learn their styles. Finally, our early focus on identifying the most problematic patients of each physician, who were then successfully treated with the assistance of the care manager, also helped build trust and ease the medical team into understanding and using the model.

The development of patient-centered collaborative care teams is a core tenet of health care reform, at a time when the culture of cross-education and training is quite limited. Collaboration requires team members from various disciplines to develop a common language, loosen hierarchical structures, pool bodies of knowledge and theories, and jointly develop new methods and analytical techniques within a philosophy of whole-person care. In this sense, the patient is also considered a vital part of the team. Without a doubt, collaborative care teams offer the best hope for achieving quality health care outcomes, particularly for vulnerable populations and patients with multiple comorbidities.

Financial disclosure:Dr Sanchez had no relevant personal financial relationships to report.