Because the MIDUS approach requires collaboration from a number of different departments, as well as a change in the workflow of the clinic, it’s important to get stakeholder buy-in prior to implementation.
While this approach requires a shift in the way providers currently work with patients, it ultimately allows the entire healthcare process to be more efficient and provide high-quality patient care. Listed below are some of the challenges this model can help address:
Limited time to address mental health concerns during primary care appointments
Prior to integrating and implementing a collaborative care model, our HIV physicians (like those in many clinics) struggled to adequately address mental health during the 20 – 30 minutes allocated for each patient visit when other health issues also needed to be prioritized. Patients would often raise mental health concerns at the end of the visit, leaving little time for the physician to learn more. Screening with the PHQ-2/PHQ-9 allowed physicians to know whether the patient was experiencing depressive symptoms before they even enter the exam room. Physicians could then constructively use their visit time to further evaluate these symptoms or to preemptively engage the behavioral health manager (BHM) to assist in evaluation and management. This process shifted much of the care for depression from the primary HIV provider to the BHM, freeing up time for the HIV provider to focus on other health issues. At the same time, the patient was designated a BHM to address depression and other related mental health problems.
Long waiting periods for psychiatric referrals
Another common challenge encountered in delivering mental health care has been the long waiting period patients experience when they are referred for psychiatric services. This waiting period can range from weeks to months. These long waiting periods may mean clinicians miss the brief window of opportunity available to engage patients in their mental health care. In addition, the long wait-times often discouraged physicians from referring patients for a psychiatric evaluation in the first place. The MIDUS approach included weekly case consultations between the BHMs and the consulting psychiatrist (CP). This approach allowed for timely review of a patient’s progress, providing an opportunity to intervene early when patient symptoms were increasing, and if necessary, a referral for direct psychiatric evaluation.
Suboptimal care for patients with recognized depression
Two-thirds of patients identified with depression in our clinic were already given a diagnosis of a depressive disorder from previous providers. Implementing measurement-based care (use of regular measurement with the PHQ-9 to assess response or remission) and providing additional support from a BHM facilitated effective patient treatment and made it more likely that remission would be achieved.
Negative HIV health outcomes among patients who are depressed
Patients with symptoms of depression report discontinuing the use of their HIV medications, disengaging from care, and missing follow-up appointments. Improving the clinic’s process for addressing mental health concerns was an avenue to improve both mental health and HIV outcomes.
Substance abuse prevalence amongst patient population
The prevalence of substance use disorders can impact psychiatric disorders which in turn affect the rate and course of treatment. Many patients with substance use disorders suffer from depression and other mental health concerns. During the implementation of the collaborative care model, patients discussed substance abuse problems with BHMs who assessed motivation for treatment and referred accordingly. BHMs provided education regarding the impact of substance abuse. They utilized motivational interviewing strategies to facilitate change. When relevant, they referred patients for more intensive treatment. Addressing psychiatric symptoms allowed for a greater likelihood of success with the treatment of their substance use disorder.