Table 5 Facilitators 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

Patient engagement

 Appointment flexibility

 DCM proficiency in engagement

“[She is] very accessible, great clinician…Engaging person which is necessary. She reaches out to the physicians and residents, and they know she is very available except when in session. People knock on door for emergencies.” (Sustaining Admin)

 Personalization/education/motivational messaging

“[Message] framing so that avoid stigma” (Opt-in PCP); “Staff matches patients culturally and DCMs are all bilingual in Spanish.” (Opt-in Admin); Engage: Gave gift card/ metro card, health first, talk about depression in positive way, e.g. many will not say depressed, feeling sad” (Opt-out Admin); “Newsletter to talk about positive stories” (Opt-in PCP)

 Reminder system

 Warm handoffs

“[When you perform] warm handoffs, then many more [patients] follow up, maybe 80%” (Opt-in DCM)

Provider/staff engagement

 Provider/staff communication

“Mini-teams of Patient Care Administrator + Registered Nurse + PCP will help increase personal accountability for patients.” (Opt-in Admin)

 Engage staff

“Involve ALL of the staff, including support staff (nurses, MAs, clerical staff) because it is a culture transformation.” (Opt-out Admin)

 Engage PCPs

“Scripting to the PCPs that this will help your panel look better.” (Opt-in DCM)

“PCPs join interdisciplinary meeting with psychiatrist and DCM. Scheduled at 1 pm during shift from morning to afternoon and food is provided.” (Opt-in Admin)

 Optimize use of psychiatry

“Psychiatrist: 50% face to face visits, 50% for chart reviews, case supervision with team, PCPs come to meeting that psychiatrist. Psychiatrists fill with 3–4 month waiting list quickly, so reserving time for not face-to face allows for more population health model. The psychiatrist sees patient only 1–3 times max.” (Opt-in Admin)

Personnel resources

 Add personnel resources

“We are looking for a SW but unable to find one. Salary offered is very low and the other people not qualified and thinking about increasing the level.” (Opt-in Admin); “The DCM should be co-located in the clinic.” (Opt-in Psych); “More staff: another DCM, more MAs, practice manager…More time with psychiatrist would be helpful.” (Opt-out DCM)

 Paraprofessionals

“The data manager [paraprofessional] sends referrals to the DCM and administrator, scheduled appointments, calls patients as reminders, and adds patients to the list for billing purposes.” (Opt-in Admin) “Patient educator allows SW to practice at top of license: appointment reminders, check in on treatment care goals, scheduling, in between DCM appointment contact. Makes sure patient fills new prescription, takes meds. If they have questions, helps monitor the registry” (Opt-in Admin)

Training

 Billing training

 Ongoing training

“A coach teaches care managers engagement [strategies] and [staff] how to get an accurate PHQ score… [there is also] training in motivational interviewing… quarterly training, certification is intensive” (Opt-in DCM). “When you have new residents or attendings, they need to be trained.” (Opt-in Admin)

Screening/referral

 Screening/referral logistics

 Flexibility/QI

 Standardization

“Psych Nurse Practioners (NPs)/Physician Assistants (PAs) came to teach MAs how to do a PHQ-2,-9, which really helped. After the training a competency was developed, and the MAs were evaluated…This was very helping in improving screening rate and quality.” (Opt-in Admin) “Developed a protocol for medication management for depression which is VERY prescriptive. Start sertraline on certain schedule, then add bupropion, etc. 90% of the time that people do not achieve remission is because they have not followed the protocol.’ (Opt-in Admin)

External factors

 Healthcare system

“A lot of systems do not credential SW’s to bill. So coming up with a more streamlined approach to SW billing for hospital systems so that they have an incentive to do it.” (Opt-in PCP)

 Leadership commitment

 Optimize long-term/community mental health

“More services would make this program better, specifically group therapy and substance abuse treatment.” (Opt-in Psych)

 Leverage national/primary care initiatives

“This model of care fits with clinic’s Patient Centered Medical Home (PCMH) activities which was helpful.” (Opt-in Admin)

Information technology (IT)

 Optimize EHR/registry

“If the EHR could feed into the registry, which would eliminate redundant data entry.” (Opt-in Admin)

 Dashboard/mobile technology

“We are putting PHQ-9 on iPads. Idea is to have patient fill out PHQ9. If patient screens positive, will pop up on PCP screen. If question 9 is positive [suicide question], then a hard stop will come up requiring risk assessment.”

 IT consultant

“IT person is mandatory for data collection, data analysis, and EHR updates with alerts or other changes to both be user friendly and meet the needs.” (Opt-out Admin)

 Telemedicine/psychiatry

“Psychiatric e-consults: If PCP has a question that involves psychiatric med management (NOT a diagnostic question); they use EPIC to send a message to the care manager. Each week they sit down with the psychiatrist for 10-12 min/consult to review chart and make multiple recommendations. These are primarily bipolar disorder or more complex patients, which has reduced face to face encounters by >50%.” (Opt-in Admin)

Funding

 Increase funding

 Leverage current funding streams

“DOH PCMH Patient demonstration project: grant obtained in late 2012 – this helped roll out PCMH model and hire part time LCSW.”

Accountability

“Tracking data at provider level - what site or SW has best patient engagement?” (Opt-in Admin) “Follow up with provider and a lot of support to make sure that every patient screened who is referred.” (Opt-in DCM) “Accountable to program using data and transparently showing data to the entire team” (Opt-in Admin)