Sustainability of collaborative care management for depression in primary care settings with academic affiliations across New York State

Abstract

BackgroundIn a large statewide initiative, New York State implemented collaborative care (CC) from 2012 to 2014 in 32 primary care settings where residents were trained and supported its sustainability through payment reforms implemented in 2015. Twenty-six clinics entered the sustainability phase and six opted out, providing an opportunity to examine factors predicting continued CC participation and fidelity.MethodsWe used descriptive statistics to assess implementation metrics in sustaining vs. opt-out clinics and trends in implementation fidelity 1 and 2 years into the sustainability phase among sustaining clinics. To characterize barriers and facilitators, we conducted 31 semi-structured interviews with psychiatrists, clinic administrators, primary care physicians, and depression care managers (24 at sustaining, 7 at opt-out clinics).ResultsAt the end of the implementation phase, clinics opting to continue the program had significantly higher care manager full-time equivalents (FTEs) and achieved greater clinical improvement rates (46% vs. 7.5%, p = 0.004) than opt-out clinics. At 1 and 2 years into sustainability, the 26 sustaining clinics had steady rates of depression screening, staffing FTEs and treatment titration rates, significantly higher contacts/patient and improvement rates and fewer enrolled patients/FTE.During the sustainability phase, opt-out sites reported lower patient caseloads/FTE, psychiatry and care manager FTEs, and physician/psychiatrist CC involvement compared to sustaining clinics. Key barriers to sustainability noted by respondents included time/resources/personnel (71% of respondents from sustaining clinics vs. 86% from opt-out), patient engagement (67% vs. 43%), and staff/provider engagement (50% vs. 43%). Fewer respondents mentioned early implementation barriers such as leadership support, training, finance, and screening/referral logistics. Facilitators included engaging patients (e.g., warm handoffs) (79% vs. 86%) and staff/providers (71% vs. 100%), and hiring personnel (75% vs. 57%), particularly paraprofessionals for administrative tasks (67% vs. 0%).ConclusionsClinics that saw early clinical improvement and who invested in staffing FTEs were more likely to elect to enter the sustainability phase. Structural rules (e.g., payment reform) both encouraged participation in the sustainability phase and boosted long-term outcomes. While limited to settings with academic affiliations, these results demonstrate that patient and provider engagement and care manager resources are critical factors to ensuring sustainability.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0818-6) contains supplementary material, which is available to authorized users.

How do care providers evaluate collaboration? - qualitative process evaluation of a cluster-randomized controlled trial of collaborative and stepped care for patients with mental disorders

“…Thus, our results can, at least to a certain extent, be transferred to other countries and regions, especially to care provided without co-location. Although the present study provides insights into collaboration in CSC models, further research is needed as to the sustainability of such models outside of trials, as this has been identified as challenge [ 46 ].…”

Population-based implementation of behavioral health detection and treatment into primary care: Early data from New York State

“…Previous literature suggests that even with a great deal of TTA geared toward implementing CoCM, NYS CCMP practices still needed post-implementation support to succeed in sustaining it (19). OMH has used the data in clinics' quarterly metrics reports to identify areas for quality improvement and reached out to speci c clinics for targeted, post-implementation TTA.…”

“…Recent studies have demonstrated the importance of TTA in ensuring successful implementation and outcomes. In addition, they found most real-world implementations of CoCM actually see outcomes below that of RCTs and those that NYS has achieved (19). Future studies may take a deeper dive into the nuances of TTA such as the impact of different types, i.e., individual coaching calls vs. webinars or group trainings, and could also further de ne intensity.…”

Process evaluation of a cluster randomised intervention in Swedish primary care: using care managers in collaborative care to improve care quality for patients with depression

“…In our study the PCC managers underlined the benefit of the targeted financial resources from the region for overcoming obstacles, which gave opportunities to replace the nurse who took on the role of care manager. Previous studies have shown that economic incentives are important when implementing collaborative care [21, 23, 26] and for encouraging change and improving long term results [27].…”