The chief of the infectious disease division was supportive of collaborative care, as was the chairman of the department of psychiatry. Since the successful implementation of collaborative care, there has been interest in other departments such as Family Medicine to implement collaborative care. The hospital has generally been supportive of population-based health, and collaborative care is in line with population-based health.
Management and Role Changes
Physicians began interfacing with care managers regarding mental health issues. Social workers have transferred some of the tasks pertaining to mental health to care managers. Dr. Avery took on a management role with the project in infectious disease and Dr. Lavakumar in psychiatry. “Buy-in” with implementing collaborative care has been good overall, but to some extent, variable among providers.
Legal, Zoning, or Authority Issues
Dr. Lavakumar had a brief dialogue with risk management about the implementation of collaborative care. We discussed that it is an evidence-based treatment model. The collaborative care team was assured that members would be defended in the case of a lawsuit. Risk management was in support of the model, given evidence indicating improved outcomes.
Human resources was actively used to recruit care managers, and it was an effective strategy.
Insurance / Medicare / Medicaid
Private insurance and Medicaid do not reimburse for collaborative care. Since the implementation of collaborative care, Medicare has begun reimbursing for collaborative care services. MetroHealth is in the process of initiating billing for Medicare for collaborative care.
Service Coding and Billing Changes
Care managers bill for diagnostic evaluations (mental health assessments) and are starting to bill for collaborative care services, which will help with financial sustainability. Clinics that receive Ryan White funding may be able to secure funding for collaborative care services through this mechanism.
There were no HIPPA concerns within MetroHealth since all communications set up in HIPAA compliant manner. We continue to face challenges when communicating and coordinating care with community mental health agencies outside of MetroHealth due to misinterpretation of HIPAA. As a result, obtaining mental health records and speaking with outside providers can be cumbersome.
Getting screening and re-measurement algorithms built into the EMR took surprisingly long. When our clinic location moved, which it did twice during the project, the EMR would need to be re-configured. An electronic registry is embedded in the EMR and allows for care managers to see who is overdue for re-measurement as well as who to review in case consultation.
Verbal recommendations were initially provided to the care manager, who relayed these to patients and providers. We switched to written communications in the EMR. Written rather than verbal communications from the consulting psychiatrist proved better at minimizing communication gaps regarding patient care and provided documentation for later reference.
Patient Concerns Working with the BHM
Generally, patients were very receptive to the care managers. The primary care physician typically introduced patients to the care manager. Sometimes, social workers were the de facto mental health provider in the HIV clinic before the initiation of collaborative care and had strong relationships with patients and introduced patients to care managers. Care managers function as “supporters” and “facilitators” of patient care with the patient at the center of their attention. In a minority of cases, patients are not interested in engaging with a care manager. Some of these patients do engage over time.
Stumbling Blocks/Lessons Learned
Follow-up with patients every 2-4 weeks, as typically done in collaborative care, is challenging for a variety of reasons. Two of the most significant barriers are that some patients do not have consistent phones, the frequency of symptoms and thus the volume of patients is greater than in a general primary care setting and there is a limited amount of time available from care managers.