5 Ways Collaborative Care Programs Fail
Research has credited the collaborative care model (CoCM) as one of the most effective ways to integrate behavioral health into primary care. Among other benefits, it delivers better outcomes for patients, improved patient and provider satisfaction, and increased access to care. With results like that, it is no wonder organizations are allured by the results.
So, what’s the down side? To be effective, collaborative care requires a fundamental shift in primary care operations. For all the benefits it brings, there are just as many ways it can fail. The best way to mitigate that risk is through thoughtful implementation and consideration of potential pitfalls before the program ever begins.
In this article, we break down five of the most common reasons collaborative care programs fail – and how to avoid them.
(This article assumes you’re already familiar with the model. If needed, check this out for a refresher on how the collaborative care model (CoCM) works.)
#5: Lack of Primary Care Provider (PCP) Engagement in the Collaborative Care Program
As the primary referral source in collaborative care, primary care providers (PCPs) are essential to a successful CoCM program – and ultimately responsible for the overall quality of care. So, it should be no surprise that a lack of “buy-in” from a CoCM program’s PCPs will degrade the program’s performance.
Why wouldn’t a PCP “buy in” to CoCM?
A PCP’s working life is already incredibly full. On any given day, they have many responsibilities and likely leverage many technologies to fulfill those. So, a new program requiring changing their workflow may feel like an undue burden if it is not abundantly clear what they will get out of it. Collaborative care will require learning a new approach. It will require new meetings with other care team members. It may require new technology. For some, this may be overwhelming.
If your program intends to begin universal screening for behavioral health conditions, this issue can be particularly acute. Screening will likely uncover many more patients in need of behavioral health services that the PCP will then be responsible for overseeing.
What can I do to help a PCP see the value of the CoCM program?
Research indicates that the collaborative care model demonstrably improves the quality of life for primary care providers. On average, it saves PCPs 2 minutes per appointment per day. Further, it allows them to spend more time practicing at the top of their license.
The care manager (CM) can relieve some of a PCP’s burden by responding to patient messages and completing most follow-ups. Further, many of the patients that are frequent visitors to primary care have comorbid behavioral health issues – and the CM can take some of the load for these patients, too.
Primary care providers often have an ‘aha’ moment during the early stages of a CoCM program kick-off – when they suddenly see how it will make their lives easier. The key is getting PCPs to engage with the program until they get to that point. Helping PCPs understand the benefits to both themselves and their patients is essential to overall program success. An effective collaborative care team needs PCPs to not only act as participants but advocates for the model.
Need help with engaging PCPs around the collaborative care model? Implementation with Mirah includes this. Reach out to learn more.
#4: Too Many Severe Cases in the Program’s Collaborative Care Caseload
Although CoCM was originally developed to address mild to moderate depression and anxiety in adults, many clinics now use this model to address all levels of severity, including higher acuity. However, research shows that for a CoCM program to be effective in the long term, it needs to maintain a balanced caseload of patients with mild, moderate, and severe symptoms. Patients with more complex needs can utilize the program in order to help navigate access to a higher level of care, such as Intensive Outpatient Program (IOP) or specialized behavioral health treatment.
What is a “balanced caseload” in collaborative care?
Collaborative care is most effective as a short intervention, begun soon after a patient begins experiencing symptoms. By addressing acute mental health distress early, patients can be more effectively treated to remission, which opens space up in the program for another patient. In CoCM, the average episode of care is around six months.
If your CoCM program’s caseload has predominantly severe patients, you end up with two notable issues:
Severe patients typically require significantly more care to see an effect. This means that the more severe patients you have, the fewer patients the care manager can support at once – which both reduces the financial health of the program and limits overall access.
Severe patients typically need to receive care for a longer duration, which limits access to the program for other patients. Collaborative care is most effective when it is immediately available to the entire population without a long wait to get in.
What can I do to improve my collaborative care caseload?
To improve your caseload, carefully monitor the intake severity of your patients. Aim for an 80/20 split: 80% mild-moderate cases and 20% (or less) severe cases. This balance allows you to address a wider range of needs while optimizing workflow and workload. If the number of patients with severe symptoms is too high, consider referring directly to speciality care.
For patients already in the program, use regular psychiatric consults to determine whether a step up in care might be appropriate. If a patient isn’t progressing on their treatment plan, it may be time for a change.
#3: Not Properly Staffing Your Collaborative Care Team
The ratio of care managers to PCPs varies depending on the needs of the setting – from 1 CM per 5 PCPs in areas without a high prevalence of behavioral health issues to close to 1:3 for those serving more complex populations.
Regardless, the point to CoCM is to expand access and make behavioral healthcare available to those that need it. Without enough staff, the program ceases to be a universal option for patients.
What happens if we don’t have enough staff in our CoCM program?
In most circumstances, CoCM is financially sustainable as long as each care manager cares for enough patients to cover the cost of their own salary, plus a small overhead for consult time, etc. However, the model was designed specifically to help deliver timely access to needed behavioral health services. So, if there’s a waiting list to get in, then suddenly many of the same problems appear that have plagued specialty behavioral health for years: inconsistent outcomes and patient satisfaction, more complicated workflows, and more administrative time.
Understaffing creates a vicious cycle. Without enough staff, PCPs might stop referring patients they know won't receive timely care within the program. This can lead to fewer patients overall, which might then necessitate staff reductions - even though initial understaffing was the problem.
How do I get more staff for a collaborative care program?
In many states, collaborative care codes allow non-licensed staff to serve in the role of the care manager. This flexibility in staffing can be particularly helpful in areas with limited access to behavioral health professionals.
In this scenario, care managers do not provide psychotherapy, but do assist with sub-clinical interventions such as: psychoeducation, resource sharing, behavioral activation, and communication across the treatment team. CMS requires the care manager to have “some level of behavioral health training.” This allows healthcare systems to recruit from their local community and staff with language and cultural awareness, similar to community health workers.
Many Mirah customers also partner with staffing agencies that are experts at finding and placing staff. This may be an option for you. We can help.
Want to learn more? Let’s chat.
Finally, retaining the staff you have is also a key concern. The fewer staff you lose, the less you will need to hire.
The best way to do this? Cultivate a supportive and respectful program environment. Build a strong sense of community by encouraging open communication, celebrating successes together, and actively seeking team member input. Make sure team members feel valued and empowered to share ideas. This fosters a sense of agency, improving job satisfaction and reducing turnover.
#2: Lack of Referrals into Your CoCM Program
What happens without enough referrals in collaborative care?
A CoCM program can only be successful if it is actually treating patients. And those patients? They need to be referred by the PCP into the program.
If you don’t have sufficient referrals, the CM will not have enough cases to work on to cover their salary - putting the financial stability of the program at risk.
How can I improve referrals into my CoCM program?
Universal screening can help identify patients who might be in need of services and who have emerging concerns with mild symptom presentations.
PCPs are sometimes hesitant to refer patients who are only mild in severity. These are, however, the perfect patients to refer into the program. Make sure your program’s PCPs understand the importance of balancing your caseload and understand why. By addressing mild behavioral health symptoms, such as mild depression with sleep disruption, CoCM can prevent symptom progression and even crisis down the road.
Be certain that your care manager/s have enough open time to immediately intake patients into the program when needed (also known as a “warm handoff”). If a care manager’s time is overbooked and this is not possible (also known as a “delayed handoff”), patients may lose interest.
If you are doing a delayed handoff, you may experience lost patient interest between referral by the PCP and enrollment by the care manager. Ensure that patients are being given enough context on the value of the program by the PCP to help retain their interest in the program.
#1: Lack of Program Financial Sustainability
Many promising collaborative care programs, funded by grants and praised for their impact, ultimately face discontinuation due to unsustainable financial models that cannot cover long-term program costs.
What is the main driver of financial success in a collaborative care program?
In a typical collaborative care program, the largest expense is personnel costs while, for a fee-for-service-based program, the largest source of income is the monthly per-patient billing charge.
This means that the largest driver of overall program financial success is the number of patients that each care manager can support per month.
How can I optimize each care manager’s caseload?
Optimizing care manager workflows and leveraging technology can maximize their impact on more patients, improving both efficiency and revenue.
Some ways to do this:
Track minutes spent carefully, capturing every minute of service rendered. This includes even small tasks that only take a few minutes, such as answering a quick question. They all add up.
Spend the right amount of time on the right patients. A patient who only needs a few minutes of attention per month might be a good candidate for discharge; a patient who regularly needs eight hours of care per month may need a step up to a higher level.
Minimize non-billable time. If you need to spend significant time working out what you should be doing or doing non-billable administrative work, you may benefit from technology to help you prioritize and/or minimize the burden.
In general, technology can help in all of these areas - that’s why we built a solution for behavioral health integration.
