In this session we re focusing on a high level overview of the Collaborative Care approach.

Transcription

1 In this session we re focusing on a high level overview of the Collaborative Care approach. 1

2 The evidence base for collaborative care is extremely strong. More than 80 RCTs demonstrate this approach is more effective than usual care for common mental health conditions such as depression and anxiety. How much more effective is collaborative care? 2

3 Here s the bottom line. Twice as many people get better. So you may be saying to yourself, that s great, but what about PTSD and bipolar disorder, which are the target conditions for SPIRIT. Several studies have shown that Collaborative Care also works for more complex patients. And we also know this from the experience that we ve had over the last decade since we ve started working with community health centers in Washington state to provide Collaborative Care. The program started out treating patients with depressed patients, but we quickly found out that many of these patients have PTSD, or have bipolar disorder. So we know that Collaborative Care can work, and in the SPIRIT project, we ll be asking the question of how well Collaborative Care works for patients with PTSD and bipolar disorder compared to direct treatment by a psychiatrist or psychologist. 3

4 This slide demonstrates the principles of collaborative care. It also shows the tools and resources needed to support the work of collaborative care. 4

5 Here s a representation of usual primary care where you can see the provider and patient working together, with little support or connection to resources outside the clinic. 5

6 This depiction highlights the additional supports that Collaborative Care provides. It adds two new people to the care team: the care manager and the consulting psychiatrist, and with the care manager s central role in care coordination, links resources and supports together so they function effectively to help the patients. 6

7 At a very high level, the Collaborative Care Clinical workflow looks very similar to a workflow that you could envision for any chronic health condition, but here in the first step, we explicitly highlight patient engagement and education as a critical foundation for the process. 7

8 This slide shows a quick cheat sheet of all the tasks for each of the steps of the SPIRIT collaborative care workflow. These documents are available on the SPIRIT website, and you can also print them out and keep them close by for reference. When you are first getting started or if you are in a small clinic and some time elapses between your SPIRIT patients, then this can serve as a reference and checklist to remind you about the steps. 8

9 In SPIRIT, everyone will receive 12 months of clinical services through the study. We will continue outreach efforts for the full 12 months, even for those people who are really tough to engage. We also want to set the expectation that most people will need to have their treatment adjusted in order to get the best response. This is no different from needing to adjust and optimize treatments for hypertension, diabetes, or asthma. Among depressed patients, 50-70% need at least one change in treatment before they achieve significant improvement, and we would expect that this will be true among SPIRIT patients as well. Prior research studies have confirmed that changes in treatment really matter and that every change in treatment gets as many as 20% more patients better so it s important not to give up too soon.

10 This graph shows data from the WA State Mental Health Integration Program (MHIP) in 2009 and 2010 to illustrate how critical it is to front load care management with early engagement efforts. On the bottom, we have time in treatment and along the Y axis we have the percent of people who improve, in this case, this is improvement from depression. There are 2 lines, the solid line is all the patients who had a follow-up care management visit within 4 weeks of their initial assessment, and the dotted line is all the people who did not follow up in those critical first 4 weeks. The take-home message is really simple: far more patients got better if they were seen back quickly. This is true at every time point over the next 6 months. So what you do in those first weeks matters a lot in terms of getting your patients better. What you can also see is that persistence pays off, and you can really expect to see improvement in a lot of patients within 6 months if care managers invest time and effort early in the course of treatment. I mentioned that this graph shows outcomes for depression, but we have no reason to think things will differ for people with PTSD or bipolar disorder. They are a more challenging population, so the lines overall may be a little lower and that s one reason we re giving everyone a full 12 months of treatment. 10

11 Active treatment is until patient has significantly improved or stabilized. This consists of a minimum of 2 care manager contacts per month, which can be in clinic, by phone, or a combination. Once a patient has achieved their treatment goals or entered remission, or- if they will not benefit from further adjustment in treatment, their follow up can be reduced to once per month and they will be either in maintenance (for those who didn t make it to remission) or relapse prevention. Study services last for 12 months, so it will also be important to plan for appropriate post-study services which may be referring stable patients to primary care follow-up, or for people who are highly symptomatic, this may involve working with them to connect them to the local community mental health agency, which of course can take some time to get into place.

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