Collaborative Care Revisited: Addressing Mental Health Through Primary Care & Case Management

Source: CMSA Today

BY GARRY CARNEAL, JD

With mental health concerns fresh on our minds since the pandemic, case managers continue to focus on their patients’ mental well-being, in addition to an array of physical ailments. Over time, the interaction between mental and physical health has become more apparent. Case managers have been very aware of the mind-body connection for years. For instance, the Case Management Adherence Guidelines (CMAG) showcases the importance of a patient’s disposition regarding their willingness to engage in their treatment plan (Reference 1).

Many studies and articles have documented the lack of support for mental health and substance use disorder (MH/SUD) conditions when patients visit their primary care physicians. This represents a significant lost opportunity.

Can case managers contribute in this setting similar to what they have accomplished in traditional care settings where they are dealing with chronic conditions, readmission prevention and other complex health challenges? The answer is yes! Case managers have a unique opportunity to help fill that gap by working with patients and their primary care physicians through the “Collaborative Care” Model. This intervention program has established a proven track record in improving population-based outcomes and is worth re-visiting (Reference 2).

The Concern

Mental health conditions continue to dramatically impact the U.S. population. Forbes Health just published some statistics that remind us of the severity:

• Anxiety. Anxiety disorders such as generalized anxiety, obsessive-compulsive disorder and panic disorder are some of the most commonly diagnosed mental health conditions in the U.S., affecting 42.5 million adults.
• Depression. 21 million U.S. adults are living with depression, while 3.7 million people ages 12 to 17 experience major depression and 2.5 million teenagers experience severe depression.
• PTSD. There are 12 million U.S. adults living with post-traumatic stress disorder.
• Bipolar Disorder. 3.3 million U.S. adults experience bipolar disorder.
• Schizophrenia. 1.5 million U.S. adults have been diagnosed with schizophrenia. (Reference 3)

Addressing undertreated mental healthcare conditions, in conjunction with medical physical conditions, in primary care settings represents a significant opportunity for case managers (Reference 4).

The Intervention

The Collaborative Care Model specifically integrates care between providers to improve common mental health conditions such as depression and anxiety in primary care. In a traditional doctor’s office, the treatment team usually consists of the physician, or physician assistant, and a nurse. Using the Collaborative Care Model, at least three clinical team members are typically involved: 1) the treating practitioner; 2) the case manager (who often is embedded onsite); and 3) the psychiatric consultant (who is typically engaged via phone or video link).

As highlighted by the American Psychiatric Association (APA), the “Collaborative Care Model differs from other attempts to integrate behavioral health services because of the replicated evidence supporting its outcomes, its steady reliance on consistent principles of chronic care delivery, and attention to accountability and quality improvement” (Reference 5).

Key features include:

• Patient-Centered Team Care. The case manager promotes collaboration with the primary care and behavioral health provider by developing care plans that incorporate patient goals. The patient is often more comfortable and open to the treatment plan when it is presented in their doctor’s office.
• Population-Based Care. The care team tracks and shares key information through a patient registry, similar to how a care management software system tracks patients. This promotes the systematic tracking and updating of patient medical information, which can be facilitated by the case manager between visits to the primary care office.
• Measurement-Based Treatment. The case manager works with the other care team members to track the patient’s treatment plan with specific goals and clinical outcomes in mind. These in turn are measured by evidence-based tools, such as the case management adherence guidelines. Treatments are then actively updated to optimize the clinical outcomes.
• Evidence-Based Care. Treatment pathways are identified by the care team that utilize the expertise of each healthcare professional, which helps treat the patient more wholistically. A best practice would be to integrate a care treatment plan for each patient that factors in their mental and physical co-morbidities.
• Accountable Care. The care team is held accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided (Reference 6). The reimbursement methods will depend in part on who the funder is for those services.

The Evidence

The evidence behind the Collaborative Care Model is clear and compelling. Approximately 10 years ago, several focus groups were facilitated through the Kennedy Forum that looked at pathways to promote integrated care. The Collaborative Care Model was identified as a top priority during these proceedings. The findings were eventually published in an issue brief (Reference 7).

Here are some of the key findings that were published in that issue brief:

• Documented Outcomes. Approximately 80 randomized controlled trials have shown Collaborative Care to be an effective treatment model for treating common mental health conditions such as depression and anxiety. Research shows Collaborative Care improves patient functioning at home and work, reduces disability, improves clinical outcomes, increases patient satisfaction and improves quality of life.
• Mental Health Focus. The research findings are particularly strong for addressing depression. In addition, there is a growing body of evidence that Collaborative Care can effectively help treat other conditions including anxiety disorders, post-traumatic stress disorder and co-morbid medical conditions such as heart disease, diabetes and cancer.
• Substance Use Disorder (SUD) Follow-Up. Although the research behind Collaborative Care’s ability to effectively treat substance use disorders is less established, current research does show patients who have comorbid mental health and substance use problems can benefit from Collaborative Care. For example, some Collaborative Care programs handle a variety of SUDs, including alcohol screening and brief interventions. In addition, Collaborative Care programs can engage patients in care for alcohol use disorders when they are not ready for specialty treatment.

Several recent studies highlight how Collaborative Care is making a difference. A 2022 study highlights four different settings where this integrated approach is making positive improvements in different populations:

• students in university
• woman’s health for perinatal depression
• geriatric health as part of a whole health solution
• treatment for substance use (Reference 8).

Cost Savings

Some stakeholders such as funders and primary care doctors initially questioned the value of the Collaborative Care Model because primary care offices were bringing on additional staff. What has been found, however, is that there is a financial return on investment (ROI) in addition to the clinical improvements.

Collaborative Care not only improves patient care experiences and health outcomes, but also reduces population-based medical expenses. The largest trial of Collaborative Care to date is the Improving Mood – Promoting Access to Collaborative Treatment (IMPACT) study for depression care, which tested the model on older adults treated in primary care clinics in five states. Results from the study found substantial reductions in long-term overall healthcare costs in patients who had received Collaborative Care. The overall ROI was $6 in healthcare costs saved for each dollar spent on depression care (Reference 9).

Payment

Compensation for case management services is always an important factor to consider, especially when expanding to a new area for case management. Initially, payment for Collaborative Care programs was a sticking point because it was not clear how this model would get funded. This changed when the U.S. Center for Medicare & Medicaid Services led the way with several payment codes.

As highlighted in the American Psychiatric Association’s website:

“Primary care practices that are providing collaborative care services can bill for those services using CPT® codes for Psychiatric collaborative care management services (99492, 99493, 99494 and G2214). Medicare, commercial payers, and many Medicaid plans are also providing coverage–check the local coverage policies in your area to determine coverage. Federally qualified health centers and rural health clinics can bill for these services using HCPCS code G0512 (for the initial 70-minute or subsequent 60-minute visits)” (Reference 10).

Utilization

Although the payment codes are good news, one central challenge is encouraging primary care practices to bill under these codes. Some primary care physicians tend to shy away from treating their patients for mental health conditions in part due to concerns over scope of practice and the need for follow-up care, especially after a more detailed mental health or SUD screening is used. Other concerns include risk exposure and reimbursement issues associated with the ancillary services.

Case managers are all about coordinating care for patients in a wholistic manner. A team approach is a fundamental principle of the case management process and syncs well with the Case Management Society of America’s (CMSA) professional Standards of Practice. Thus, the Collaborative Care and case management process go hand in hand.

Final Thoughts

Collaborative Care offers a new way for case managers to support patients when visiting their doctors’ office and attain reimbursement for those activities. Case managers have been known for their ability to innovate and design new population health-based programs that positively impact quality of care. Collaborative Care remains an exciting way to identify, treat and measure common behavioral health conditions. When implemented in a meaningful manner, Collaborative Care can improve clinical outcomes, increase patient satisfaction and reduce overall healthcare costs—the “triple aim” of population health.

References

1. Aliotta, Sherry L, et. al. “The Impact of CMSA’s Case Management Adherence Guidelines and Guidelines Training on Case Managers-Report Behavior Change,” Professional Case Management (Sept-Oct 2007).
2. This article provides an update of the following article: “Using ‘Collaborative Care’ to Optimize Integrated Population Health,” CMSA Today (January 5, 2021).
3. Duszynski-Goodman, Lizze “MH/SUD Statistics and Facts,” Forbes Health (published online Feb 21, 2024)
4. One recent article addressing the relationship between health outcomes and costs between MH/SUD and medical physical conditions was highlighted in the following article: “Viewing Mental Health Parity from a Population Health Perspective,” CMSA Today (September 2023).
5. 5. “Learn About the Collaborative Care Model,” Click here for American Psychiatric Association (APA) Report.
6. Ibid.
7.  “Fixing Behavioral Health Care in America: A National Call for Integrating and Coordinating Specialty Behavioral Health Care in the Medical System,” Kennedy Forum Issue Brief (2015, 43 pgs). Authors: John Fortney, PhD, Rebecca Sladek, MS, and Jürgen Unützer, MD. See kennedyforum.org.
8. Reist, MD, MBA, Christopher et. al., “Collaborative Mental Health Care: A Narrative Review,” Medicine (Baltimore) [December 30, 2022; 101(52):e32554].
9. As referenced in a Kennedy Forum Issue Brief for references including: Unutzer, MD, MPH, Jurgen et al.,”Long-term cost effects of collaborative care for late-life depression“, The American Journal of Managed Care, [Feb 2008; 14(2), 95-100]
10. “Reimbursement for the Collaborative Care Model,” See American Psychiatric Association website.

Garry Carneal, JD, MA, is best known for his work in the healthcare accreditation field, including the development for the first national standards for case management organizations. He currently serves as the President & CEO of Schooner Strategies and RadSite. He is a leading expert in healthcare having researched, written and published extensively on quality, medical management, information technology and regulatory trends. He has established a track record helping trade associations, accreditation organizations, nonprofits and other health-related businesses scale nationally. Throughout his career, Garry has brought to market over 30 accreditation programs in healthcare, including the first national accreditation standards for case management.

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