Overall, this demonstration project reveals that organizations with markedly differing characteristics were able to integrate mental health care into primary care for disadvantaged and underserved patients. In all sites, a plurality of patients experienced meaningful improvement in depression, and in some sites, the majority experienced rapid improvement following initiation of treatment. Despite these broad successes, the organizations differed dramatically in indicators of quality and in outcomes, differences that were not attributable to measured characteristics of the patients served. Moreover, the variability in quality measures and outcomes indicates that substantial room for improvement in quality of care remained.
Retention in depression treatment is poor for primary care patients, particularly low-income minorities.(25
) Outcome measures were collected exclusively in the course of clinical treatment and therefore, were obtained at different times for different patients. Consequently, many patients who did not have a PHQ-9 score between 6 and 12 weeks were counted as drop-outs for acute phase outcomes, but fewer patients (18%) were truly lost to follow-up. This rate closely approximates retention in collaborative care research trials.(1
) Moreover, our survival models accounted for attrition in constructing estimates of outcomes over time.
In research settings, around 60% of patients treated in a collaborative model experience improvement and 25% achieve remission during the acute phase compared to around 40% of patients who improve and 10% who remit in usual care. (3
) Depression outcomes are worse for complex patients, including those who are elderly, socioeconomically disadvantaged, anxious, or treatment-resistant.(3
) Although one might expect that trial results could not be reproduced by organizations in economically-deprived, minority communities serving heterogeneous patients, our results refute this notion. Several participating organizations are federally qualified health centers in poor urban border towns with high concentrations of Spanish-speakers and are safety net providers for uninsured individuals, including undocumented immigrants who are ineligible for Medicaid. At six of seven sites, half of patients improved, and at five sites more than 40% of patients achieved remission, a more challenging clinical target. Thus, these results provide robust support in demonstrating that collaborative care, when adapted by community health centers, can meet or surpass the outcomes achieved in research settings even in poorly resourced settings. This finding is highly relevant in light of strong interest in integrated healthcare in the context of national health reform.
Although all sites received the same training, guidance, and support, and all used the same web-based registry, the care provided and the outcomes achieved differed markedly. Outcomes diverged across sites as early as 4 weeks, highlighting the critical importance of the early course of treatment. For example, loss to follow-up occurred for only 4% of patients at organization 2 compared to over one-third of patients at organization 6. Organization 2 was successful in all metrics of care: 87% of patients received early follow-up; 66% had 4 or more follow-ups within 12 weeks; 68% received appropriate pharmacotherapy; and patients received an average of 4.8 contacts during the first 12 weeks. Patients treated at this clinic had excellent acute-phase outcomes, with two-thirds improving and half achieving remission. In contrast, the site with the worst acute-phase outcomes (organization 1, clinic B) performed relatively poorly on process measures, with 19% of patients lost to follow-up, one-third of patients receiving early follow-up, 5% of patients receiving 4 or more follow-ups within 12 weeks, and approximately half of patients receiving appropriate pharmacotherapy. Having conducted site visits, we have the impression that some sites implemented more effectively than others. Those sites that appeared to implement well demonstrated better performance on both quality indicators and patient outcomes. These differences were not attributable to patient characteristics. Although early follow-up was significantly associated with improved outcomes, we are not able to conclude that more patients improved because they received more intensive follow-up. It is possible that the indicators we measured tap into broader constructs of the quality of services provided across organizations and are not responsible for improved outcomes, but nevertheless associated with such outcomes.
In multivariate analyses adjusting for quality indicators, site remained strongly associated with outcomes, suggesting that the effect of being treated in a particular clinic is at least as salient as receiving (or not receiving) early follow-up or appropriate pharmacotherapy. On the surface this may appear surprising; however, this is consistent with our impression that the quality measures we quantified were indicators of broader processes occurring within the clinics. We speculate that similar patterns may have emerged if we had quantified other quality indicators. It is possible that clinics with better implementation were more likely to provide treatment intensification for patients not responding to initial treatments, effects that were not captured by our analyses. Similarly, it is possible that clinics that achieved superior outcomes were more effective in tailoring treatment to individuals’ needs, for example, by accounting for patient preferences, availability of services, and adaptation of treatment to individual outcomes.
Because a small number of organizations participated in this demonstration project, we were not able to quantitatively evaluate how characteristics of the organizations were associated with outcomes. However, with great interest in replicating collaborative care models in community settings, we speculate on some potential contributors. Several organizations located in impoverished communities with no pre-existing mental health services, little or no experience with integrated care, and few resources were largely successful in implementing collaborative care. In contrast, the organization that had the least success in program implementation was a large organization with a significant pre-existing structure of mental health providers both within primary care and at specialty sites. This existing system of separating mental health and primary care appeared to impede implementation. Despite training and additional resources, little practice change was apparent and care remained fragmented between a wide array of providers such that many patients “fell through the cracks”. Thus, building an integrated delivery model de novo may be more straightforward than re-engineering a system with existing services. Organization 4 provides an example of a success story. Although the leadership at this organization was unsupportive and at times antagonistic to the initiative, the organization had strong support from capable primary care providers and care managers who embraced the model. In this case, it appears that the clinicians were successful in enacting substantial practice change despite a lack of strong support from the administration. They engaged patients early on and provided appropriate pharmacotherapy to a majority. These examples suggest that attention to the pre-existing system of care may be an important element for organizations considering implementing an integrated model and that buy-in from on-the-ground clinical providers may be particularly crucial.
In considering the implications of these findings, several limitations are important. First, unmeasured differences in the patient populations treated across sites may account for some of the observed variability. Information was not available on individual race/ethnicity, education or income, factors that may be associated with depression outcomes. The organizations predominantly treated uninsured patients in impoverished communities, so these results may not represent organizations treating patients under more advantaged circumstances. Without data on treatment patterns and outcomes at these organizations prior to the initiative, we are unable to indicate to what extent the observed treatment and outcomes are the result of the introduction of this model. The patients treated represented a heterogeneous mixture of clinical presentations and data on diagnoses was not available for further description. Analyses were also limited by a lack of detail regarding patients’ use of psychotherapy and psychiatric consultation. Finally, medication data was obtained from the registry and may not reflect patients’ actual medication use.