Communication among members is the most essential aspect in order for collaborative care to be effective. And the team needs continued reassessment of the team-based care process and their individual roles.
The Project Champion secures stakeholder buy-in, challenges resistance among peers, provides administrative oversight, troubleshoots, and ensures complete and appropriate implementation of the collaborative model.
Behavioral Health Care Manager (BHM)
The Behavioral Health Care Manager (BHM) is an integral member of the team and often a new member. The BHM may be trained in nursing or social work. The BHM assumes responsibility for depression care within the MIDUS approach. The BHM meets with patients in clinic when initial screening indicates depressed mood (PHQ-9 >10), at follow up appointments as well as by phone or face to face in between office visits. The BHM completes diagnostic evaluations, reviews cases with the consulting psychiatrist and ensures patients are aware of treatment recommendations.
The BHM maintains regular contact with patients to encourage full engagement through physician visits, education, lab tests, viral load monitoring, self-help activities, and peer group participation. The BHM performs a significant role in integrated care for each patient, facilitating appointment scheduling and suggesting actions as needed, identifying problems as they arise, and working to resolve challenges. The BHM joins the interdisciplinary team consisting of HIV primary care staff, Psychiatrist and medical case managers to ensure patients’ needs are being met.
Consulting Psychiatrist (CP)
The Consulting Psychiatrist provides mental health expertise and ensures safe and high-quality services are delivered through implementation of the collaborative model. The consulting psychiatrist reviews cases weekly with the BHMs and makes recommendations for medications, psychotherapy or formal psychiatric evaluation. The CP details case review and treatment recommendations in the electronic medical record (EMR) and forwards this note to the patient’s primary HIV care physician. The consulting psychiatrist expands capacity for delivering mental health services through the provision of education and training for medical staff.
HIV primary care physicians are responsible for the overall health and well-being of the patient. They involve the behavioral health care manager in the care of the patient when appropriate. They prescribe psychiatric medications based on recommendations of the consulting psychiatrist. HIV primary care physicians are responsible for billing for collaborative care when appropriate.
Medical Assistants (MAs)
In addition to their roles as medical assistants, MAs ensure that each patient completes a PHQ-9 and enters the results into the EMR during intake, and alert the behavioral health care manager about positive screens via an alert in the EMR.
Medical Case Managers/Social Workers
The Medical Case Manager assists patients with other supportive services needed to engage in medical care. This may include assistance with insurance coverage, transportation, referrals to community resources including for food insecurity and housing resources. In rare cases, based on patient factors, the medical case manager might take on the role of a BHM.