A Closer Look at the Collaborative Care Model

I am currently serving as the Behavioral Health Care Manager at UPMC Shadyside Family Health Center. This has been a wonderful experience both in terms of my own learning, and in the impact this position allows me to have in the lives of patients suffering from a variety of behavioral health concerns, especially depression and anxiety. In what follows I will first outline the Collaborative Care Model which forms the basis of my position, and then I will explain my responsibilities. I will end by suggesting why such a model is perfect for National Health Corps service positions (and other year-long service positions offered by different organizations).

The Collaborative Care Model (CCM) works to integrate primary care providers (PCPs), psychiatric consultants, and care managers to improve health care outcomes for patients faced with behavioral health problems such as depression, anxiety, alcohol, and substance abuse. PCPs are generally family medicine physicians or internists and are the ones responsible for deciding on a suitable treatment plan for patients. The consultant psychiatrist can advise and support the PCP with patients presenting with unclear diagnosis, complex polypharmacy, a lack of improvement over time, or other challenges. Care managers support patients through regular contact, ensuring adherence to the treatment plan and updating the PCP and consultant psychiatrist on its effectiveness. At larger practices, CCMs might also involve other providers such as therapists. CCMs employ clinical rating scales such as the PHQ9 (for depression) to measure psychiatric symptoms over time.

My primary responsibilities as a Behavioral Health Care Manager include maintaining a registry of patients, checking-in with patients over the phone, and providing updates to PCPs and our consultant psychiatrist. The registry is a useful tool beyond just keeping track of patients receiving care. For example, the registry helps identify patients that have not been back to the clinic for follow-ups, as well as patients who have not had any marked improvement in their symptoms over the past few months. Since my registry deals with patients facing depression and anxiety, much of my conversation with patients over the phone is centered around how the patient is doing mood-wise, and any questions or concerns they might have with their current pharmacologic regimen. I am also able to provide short behavioral interventions as needed such as guiding patients through breathing exercises and helping connect patients with therapy providers in the area for more comprehensive behavioral interventions. After speaking with patients, I submit my notes from the patient encounter to PCPs and our consultant psychiatrist through our electronic medical record, highlighting any pressing concerns.

I think care manager positions that are integrated into a collaborative care model, like the one at my clinic, are ideal for short-term service positions (through the National Health Corps or otherwise). CCMs are often integrated alongside pre-existing Health Home Models which ensures that service members are engaged with underserved populations, including those on Medicaid. Working as care managers in such settings is also an opportune learning environment for service members as they help patients navigate social work, insurance, therapy, and other factors auxiliary to primary care. This exposure can better help service members provide care in the future should they decide to continue their education and work in the medical field. Furthermore, service members can create lasting relationships with the providers that they are intimately involved with in the collaborative care model, such as PCPs and psychiatric consultants. Similarly, service members have much to learn from the relationships they develop with patients as they hone patient-interaction skills, such as Motivational Interviewing.

This post was written by NHC Pittsburgh member Abu Mian. Abu serves at the Shadyside Family Health Center of Pittsburgh as a Behavioral Health Care Manager.