Penn Medicine researchers have published the first community-based study demonstrating improvements in suicidal ideation, depression, and anxiety among people with suicidal ideation who receive collaborative care services.
Collaborative care is an evidence-based approach to identifying and treating patients with behavioral health conditions such as anxiety and depression in primary care settings. The researchers examined data from Penn Integrated Care, a collaborative care model (CoCM) program that includes an admission and referral management center in addition to traditional CoCM services implemented in primary care clinics within Penn Medicine.
One of the co-authors, Gabriela Khazanov, Ph.D., a research psychologist at the Center of Excellence for Substance Addiction Treatment and Education (CESATE) at Philadelphia VA and research associate at the Perelman School of Medicine at the University of Pennsylvania, I recently spoke with Healthcare innovation about the research, which was published in BMC Primary Care.
Healthcare Innovation: Could you talk about some of the reasons why integrating behavioral health into primary care is such an important topic right now?
Jazanov: Yes of course. We know there are many people in this country who want and need access to mental health care, but it is very difficult to get it. The idea of collaborative care is that it is a way to provide mental health services within a primary care practice. That means mental health care is easier to access for people who are just coming in for regular primary care appointments, so those people don’t need to go through the process of finding care in the community on their own. It’s a way to make sure they have easy access to the services they need.
HCI: One of the things health system executives tell us is that there is an overall shortage of behavioral health providers. How do health systems establishing these collaborative care models find enough providers to include in these team-based care arrangements?
Jazanov: I think there are some ways it’s a more sustainable system. Using Penn as an example, when a primary care provider wants to refer someone to behavioral health care, they refer them to a resource center and, based on that person’s presentations or symptoms and the disorders they have and their severity, they are sent you to several different options. They could simply be referred to self-help resources, or they may see a behavioral health professional in primary care, or be referred to the community. Approximately 30% of people who are referred back to primary care for behavioral health care are for short, time-limited sessions. This is usually a 30-minute session every two weeks or every month. That’s part of the way their resources are distributed to as many patients as possible.
HCI: Does that require a different type of team setup to triage people to the right service?
Jazanov: Yes, there are usually a few different people involved. Of course, there is the primary care physician who conducts the initial session and assesses whether there is any reason for referral. There is also the mental health professional, who is typically a master’s level professional who performs evidence-based therapy. Within primary care, there is also a consultant psychiatrist. Penn’s program is unique because it also has an admission screening and referral center. It has admission coordinators at the undergraduate level who ask the patient questions over the phone about their symptoms, the issues they are struggling with, and make different suggestions for referrals.
HCI: Has Penn Medicine increased the number of primary care practices that have integrated behavioral health?
Jazanov: We started in 2018 with eight offices and now have more than 35 offices at Penn Medicine. One thing I should point out is that at first the system was operating at a financial loss, but because of the ability to bill for collaborative care and the way the system is set up, they were able to turn it into a viable program. that can be disseminated more widely.
HCI: Before we talk about this article and its focus on studying the impact on depression, anxiety, and suicidal ideation, has Penn studied whether it is having the desired impact of more patients accessing and getting mental health treatment? faster than before?
Jazanov: Yes, with a couple of caveats. This article focuses on a particular subset of people, but other articles have been published finding that it actually increases access to care. Many people are therefore provided with care, either within the practice itself or through referral support in the community, more than would be expected without this system. The caveat is that we really have no control, right? So in both this study and other studies, we know what happens to these patients within the system, but we don’t have a good idea of how many people access care outside the system.
HCI: But have there been other controlled trials on the effectiveness of the collaborative care model on mental health outcomes, or even medical outcomes or total cost of care?
Jazanov: There are many studies that show it is very effective and most of those studies have focused on patients with mild to moderate symptoms. For those patients, studies have conclusively shown that by increasing access to care, symptoms can be improved, even with relatively short periods of care.
HCI: According to the article you co-authored, it seems that many times people with more severe psychopathologies are sent outside the system to seek specialized care and sometimes have problems obtaining it. So this was asking: what would happen if those people were actually treated within the collaborative care model? And perhaps this is the first time it has been analyzed…
Jazanov: Yes, exactly. So this is one of the first studies of a naturalistic community setting where individuals, especially suicidal, were kept within the collaborative care model and not just referred. The reason we were able to look at this was because of this intake and resource center, which evaluates patients and then also bases their decisions on their symptoms, but does not exclude suicidal ideation. It does not automatically mean that all suicidal people should be referred. So we had patients with some level of suicidal ideation that was not acute. They were not in an acute crisis. We found that those patients were also able to be successfully treated within the model.
HCI: Could you briefly describe what the findings were?
Jazanov: The main finding of the article was that people within the collaborative care model had improvements in their suicidal thoughts and symptoms of depression and anxiety over the course of collaborative care. We also found that symptoms improved more with longer periods of care, but that was only up to six months. So it seemed like collaborative care is really helpful and the more treatment the better, within the six-month limit.
HCI: The article also found significant differences in decreased depression or anxiety by race, ethnicity, and age. Was it something surprising or something expected? Could that be the basis for further research to understand why this is so?
Jazanov: It would definitely be interesting to understand why that is. It aligns with some previous findings showing that collaborative care may be especially effective for minority populations, and that could be because there are potentially more barriers for those people to access mental health care: the stigma associated with it and the resources needed to access that care. . So when offered within this convenient and easily accessible system, it appears to be particularly effective. So it kind of fits with those findings, but I think we need to figure out exactly when it’s useful and also how to scale up those systems so that they can increase access more broadly.
HCI: Do you think one impact of this article could be that more places already using the collaborative care model would see more of these patients in that setting, rather than seeing them outside of it?
Jazanov: Yes. That’s exactly what we were hoping to show. And although this is not the only article that describes it, the model in which individuals are evaluated, classified and referred is particularly useful for suicidal ideation, because that evaluation exists. If someone is at serious risk, they can get the services they need. But if they are not at serious risk, they can be treated as anyone else would be treated.
HCI: You mentioned earlier that using collaborative care billing codes makes this make financial sense for Penn. But are there still barriers to health systems across the country adopting collaborative care models? Are we seeing it being widely adopted? Or are there still cultural or other issues that could make adoption slower than we would like??
Jazanov: There is still a shortage of mental health providers. There are many difficulties in accessing care, even within this system. Ideally, it would be in many more practices. There are still pretty significant barriers just in terms of finding resources. There’s a lot of management, oversight, and hiring that goes into it, so it’s not implemented as widely as it could be.
HCI: Could other value-based care models reward this and push more health systems in this direction?
Jazanov: I think it is totally true that the payment model could have this objective. Just increasing reimbursement for these types of services and for behavioral health professionals, so that they are incentivized to fill these roles within these practices, is one of the biggest things that would be really helpful for this program and other programs. .
