Table 4 Barriers to Collaborative Care implementation/sustainability 1–2 years after a 2 year-implementation program among clinics opting in vs. out of a Medicaid reimbursement sustainability initiative

Time-personnel resources

 Inadequate personnel resources

“Did not think about logistics issues, no thought of sites, ratios, right sizing, right timing of this −3.5-4 h of .1 FTE for 6 PCPs” (opt-out site)

 Competing DCM roles

“Currently, the administrator of the program (a certified care coordinator who can do problem solving therapy and motivational interviewing) is only funded for .5FTE, so the other 50% of her time is devoted to a diabetes program in the primary care clinic.” (Opt-in PCP)

 Inadequate MD resources

“[Providers] are getting hammered with increased number of items they are supposed to manage in the visit. We have to screen every patient for risk of domestic violence…falls…travel to West Africa for Ebola, and unfortunately, this [depression screening] is one more measure” (Opt-in PCP)

“Case consultation with psychiatrist did not happen. Psychiatrist available by telephone for consultation, but no set time to have him available. If you are in a crisis to call a psychiatrist this is ok, but overall not” (Opt-out PCP).

 Inadequate number of DCMs

“Only have 1 provider. It’s impossible to have her take care of all the depress[ed] people… Appointments are not always given the day of the [PCP] appointment” (opt-in PCP)

 Inadequate psychosocial resources

“At the same time, many patients want and/or need more intensive psychiatric treatment than can be offered in this setting (such as a day program or intensive outpatient treatment).” (Opt-in Psych)

 Inadequate space

Patient engagement

 Lack of patient engagement

“No shows [are a problem] because rescheduling with the psychiatrist takes another 60 days” (Opt-in Psych).

 Culture- language

“[it was] hard to recruit someone who spoke language, used language lines (had to pull staff to translate)” (Opt-out Admin).

 Infeasible warm handoffs

“[we had a] part time care manager who cannot have a warm handoff [which] is much less effective” (opt-in DCM).

 Patient nonadherence

“It’s challenging to make sure that patients continue to follow up. It is difficult because it affects the entire person and you have to get them to participate in the plan. Loss to follow up.” (Opt-in PCP)

 Stigma

Provider/staff engagement

 Miscommunication

“But if psychiatrist thinks that the medication needs to be increased, and then have to tell physician this message, which can sometimes be odd. The interaction between psychiatrist and physicians should be improved.” (Opt-in DCM)

 Lack of DCM engagement

 Lack of PCP engagement

“doctors are uncomfortable either because they might get more work to do” (Opt-in PCP)

 Provider continuity

“DCM turnover with mixed experiences of quality of DCMs” (Opt-in Admin) “Residents are not always engaged because you have to teach them all over again.” (Opt-out DCM)

 Psychiatrist engagement

“Psychiatrists not motivated or interested in this model” (Opt-out Psych)

 Staff engagement

External factors

 Healthcare system/guidelines

“We used to consider PHQ < 10 as remission, but now guidelines say it is under 5. PHQ < 5 is probably not realistic.” (Opt-in PCP)

 Competing primary care initiatives

“PMDs are getting hammered with increased number of items they are supposed to manage in the visit. We have to screen every patient for risk of domestic violence, risk of falls, etc. We’d love to screen patients for substance use” (Opt-in PCP)

 Other

Mental health infrastructure: “the sickest patients psychiatrically have to be referred out. That coordination is tough as it is difficult to collaborate with mental health providers outside of the clinic.” (Opt-in PCP).

Restrictive CC initiative enrollment “Patients who do not have Medicaid are still screened, so they get “light touches” with the DCM to help get them referred into therapy.” (Opt-in Admin)

Screening/referral

 Complicated screening/referral logistics

“Screening was initially tough given cultural barriers among patients and staff as well as tester fatigue” (Opt-in Admin). “[the] MA [medical assistants] did PHQ2 but hard to make sure to alert the doctor about PHQ2 and to do the PHQ 9 if positive” (opt-out PCP).

 Triaging patients

Funding

 Complex funding stream

“For patients with commercial insurance, each insurance has a different requirement/payment structure” (opt-out admin)

 Insufficient funding

“Billing is not enough, but it’s close. If CM’s have between 70–80 patients that they bill for consistently might break even. Cannot bill retainable for everyone. Does not cover psychiatry/PCP coordinator” (Opt-in PCP).

Information technology (IT)/Registry

 Paper referral-screening/EHR

 Registry management

“Registry has been very challenging because there is nothing automated about the registry and the amount of work to feed into the day.” (Opt-in Admin)

Training/knowledge

 Inadequate DCM training

 Inadequate physician knowledge

“Educating the PCPs, getting them more involved, have them be less afraid of prescribing and increasing the dose. They cannot see patients every month because they are so busy.” (Opt-in Psych)

Lack of buy-in/implementation readiness

“There is too much orthodoxy, so this would be better if there were more flexibility. If the outcomes are coming out well, why do you have to replicate the studies that were done?” (Opt-in Admin)