‘Of course, we work collaboratively already!’ says almost everyone when you tell them about ‘collaborative care’. The problem is that many people use the term as just one of the (often confusing) terms to describe health professionals working together, such as ‘shared care’ and ‘liaison-consultation’ and ‘integrated care’.
Except that collaborative care actually means something quite specific too, that has been extensively researched and implemented (particularly across the USA where the concept was originally developed). It is mentioned in the published draft of the forthcoming NICE guidance revision on depression, not as a type of therapy but as a way of organising care that actually improves outcomes.
Collaborative care involves the addition of new staff (‘case managers’) who work collaboratively with patients, primary care professionals and specialists in order to improve the quality of care for people with common mental health problems in primary care.
Case managers provide support, medication management and brief psychological therapies directly to patients, while liaising with the primary care team, and receiving support and regular supervision from a specialist, who might be a psychiatrist, psychologist, nurse or other senior mental health professional. This person may also liaise directly with the GP when needed too.
People under the care of the case manager are systematically followed up, and failure to attend is not assumed to be a reason for discharge – quite the opposite – frequent attempts are made to re-engage. Dropping out of appointments is not assumed to mean a person is ‘not motivated’.
Considerable efforts are made to work closely with primary care, including having regular access to and entering brief notes in GP records and having a base in the GP practice to work from.
I’ve been personally involved in two large UK randomised controlled trials – the CADET study for depression, where the psychological therapy delivered was behavioural activation, and the COINCIDE study for people with depression and diabetes and/or cardiovascular disease (who had a choice of brief psychological therapies). In both of these we trained Step 2 Improving Access to Psychological Therapies (IAPT) workers – Psychological Wellbeing Practitioners (PWPs) – to act as case managers and deliver collaborative care to patients recruited from primary care.
In my last clinical post before retiring in 2013 I worked with Six Degrees Social Enterprise in Salford to deliver collaborative care for common mental health problems to people in Greater Manchester, with step 2 IAPT workers based in GP practices acting as case managers. What we discovered was that the quality, delivery and organisation of supervision was essential to this process, to ensure that patients and service users had the best possible care. However, we found that it works best if the supervision team are multi-professional (not confined within psychology services), with medical input too, enabling us to help people with more complex problems and providing medication advice, and with everyone working closely with primary care.
Collaborative care has also been used to try and put into place step-down/seamless step back up services for people with severe mental illness who are moving back to the care of their GP. We know they may need their care to be stepped back up to more intensive mental health support from time-to time, as many people do, and they should not have to fight for access or wait until they reach a ‘threshold’ before being accepted. The aim is to provide on-going support for patient and service users, and their GPs too. Evidence here is more limited, but a large UK study PARTNERS2 is in progress with staff from specialist mental health services working as case managers.
Collaborative care really makes a difference – but it requires mental health professionals, primary care and services to work in a different way, in collaboration with each other and with patients. Perhaps the time has come to put something into practice which we know can actually change outcomes for the better?
This is the third in our blog series to coincide with the release of Relias' new mental health training courses for primary care. In part 4 of our blog series, author Linda Gask will discuss continuity of care. Subscribe above to ensure you don't miss future posts.
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