Why team care?

Collaborative or team care is different from co-located care in which mental health specialists (eg. psychiatrists, psychologists or counselors) are physically located in the primary care clinic but practice separately. Co-location changes the location of the specialist but does not necessarily create an integrated care team. In fact, one of the clinics that participated in the original IMPACT trial already had co-located mental health specialty care built into their primary care clinics. Patients in that clinic who were assigned to usual care were referred to these co-located specialists. At the end of the study, patients receiving IMPACT collaborative care had a substantially higher likelihood of having a significant reduction in depression symptoms as compared to the patients receiving co-located usual care from mental health specialists. Team care is not about location – it’s about integration and collaboration.

Who is on the team?

In usual care, the depression treatment team has two members: the primary care provider and the patient. IMPACT adds two more people: the care manager and the psychiatric consultant. The roles for each are outlined below and example job descriptions for the care manager and consulting psychiatrist are provided on the AIMS Center website:
Care Manager Job Descripton
Psychiatric Consultant Job Description

Patient
The patient is a very important member of the team and IMPACT is designed to engage the patient as an active participant in their treatment. Education about depression symptoms and treatment is essential in preparing the patient to be an active member of the team. Similarly, once a patient is ready to leave active care management it is important to prepare a relapse prevention plan with the patient to help them identify the early warning signs of depression and make a proactive plan for how to address that if it happens.

Primary Care Provider (PCP)
The PCP is a central player responsible for encouraging the patient’s participation in depression care activities, prescribing antidepressant medications, providing treatments aimed at comorbid medical conditions and for referrals to specialty mental health care when that is needed. IMPACT is designed to support the PCP is their role by coordinating treatment, providing proactive follow-up of treatment response, alerting the PCP when the patient is not improving and facilitating consultation with the psychiatrist regarding treatment changes.

Care Manager
The care manager is responsible for supporting the patient and PCP in depression treatment. The care manager does this by:

• providing patient education about depression and treatment
• supporting medication therapy prescribed by the PCP by following up with the patient after medication is prescribed to provide education, monitor for side effects, and coordinate mitigation of side effects, if needed
• engaging patients in behavioral activation or pleasant events scheduling at each contact
• offering evidence-based counseling or referring the patient for such counseling or psychotherapy
• proactively tracking depression symptoms at each contact to monitor the effectiveness of treatment
• notifying the PCP when the patient has been in treatment for more than 10-12 weeks without adequate improvement
• coordinating consultation from the psychiatrist regarding treatment changes
• completing a relapse prevention plan with the patient when they are ready to leave active care management

The typical caseload for a full-time care manager is 100-150 patients, depending on how the program is structured. In the original study, the care managers averaged 100-120 patients in active care management at any given time. This include patients in acute treatment as well as patients who have improved and who are being monitored monthly to insure that they are stable before being graduated from active care management. Some organizations split the care manager duties into the routine activities that can be handled by a paraprofessional (e.g. Medical Assistant) and those best handled by a more highly trained professional.This can be an efficient use of resources and allows the care manager to carry a larger caseload.

Care managers can be nurses, psychologists, social workers or licensed counselors.

Team Development The success of the IMPACT program relies to a great degree on each of the members of the treatment team understanding their role and the role of the other team members and feeling comfortable that they have the knowledge and skills necessary to fulfill this role. Click here for an assessment tool that can facilitate this process and identify gaps that should be addressed before program implementation. Another useful resource is the website hosted by the Geriatric Interdisciplinary Team Training Program at New York University. This website has a range of valuable resources in team development, including a Team Fitness Test, videos, books, brochures and more.

Psychiatric Consultant
The psychiatric consultant has two primary responsibilities:

• clinical consultation to the care manager and the patient's PCP
• direct patient consultation for patients who are not improving after several treatment changes or who are suspected to need specialty mental health care (e.g. bipolar, substance abuse).

The psychiatric consultant meets with the care manager weekly, either in person or by telephone. They review new patients and any patients who have been in treatment for 10-12 weeks without adequate improvement in their depression symptoms. The psychiatrist suggests treatment modifications for the PCP to consider. These weekly meetings typically last an hour.

The psychiatric consultant iis also available to both the care manager and the primary care providers for ad hoc telephone consultations and for an in-person consultation in those rare instances when that is needed. In the IMPACT trial about 10% of all patients had an in-person consultation with the consulting psychiatrist.

Recruiting and Hiring

Collaborative Care can require the participating healthcare professionals to function outside the traditional roles for which they were trained or to which they are accustomed. In collaborative care, the participating healthcare professionals rely on other team members in a way that may be new or may not be comfortable. This is important to consider when recruiting team members for these roles.

Specific components of the IMPACT program that may be new and require adjustments to existing work habits:

• proactive follow-up with patients (not waiting for the patient to show up in the clinic)
  
• routine measurement of depression symptoms with a tool like the PHQ-9
  
• retiring and changing the treatment plan after 10-12 weeks if the patient the patient’s depression symptoms are not at least 50% improved
  
• commitment to evidence-based counseling techniques