Prior to implementation the team assessed how the physicians and staff perceived the collaborative care model would fit into the existing workflow of the clinic and whether it would adequately address the problem of mental health disorders in primary HIV care. Semi-structured qualitative interviews done before implementation of the collaborative care model. A total of 11 staff members including four physicians, four social workers, and three nurses were interviewed. The interviews were then analyzed narratively, focusing on themes and ideas that were common across the multiple interviews.
Additionally, the team assessed patients perceptions about the collaborative care model, and the degree to which they found it agreeable, palatable and satisfactory.
The collaborative care model requires providers to work cooperatively and have open and effective lines of communication with other providers and clinic staff.
The collaborative care model requires providers to work cooperatively and have open and effective lines of communication with other providers and clinic staff. Through the early interviews it was evident that teamwork and care integration were ingrained in the clinic culture prior to implementation. Social workers, physicians and nurses all had high praise for their coworkers, with all interviewees emphasizing the collaborative nature of the clinic.
Additionally, each staff member had a good understanding of their own levels of expertise and limitations, as well as their colleagues’ expertise and limitations. For example, because of their experience treating the social determinants of health, social workers have a better grasp of how support groups, self-management techniques, and understanding other social aspects of a person’s life can help in treating a patient’s depression. A physician’s expertise, on the other hand, is primarily medical-based treatments for treatment, and they are therefore more likely to recommend an evidence-based antidepressant or refer the patient to psychiatry. Either option may be appropriate therapies for a patient, but more importantly, both the doctors and social workers know their own limitations and can count on the other’s expertise if necessary. Open discussion and communication between providers is always better for patient care, especially in treating challenging mental health cases that may be multifactorial in nature and require a multi-disciplinary response.
Open discussion and communication between providers is always better for patient care, especially in treating challenging mental health cases.
Several barriers and obstacles to adequate mental health care among people living with HIV were identified, along with how the new model could address these gaps. Physicians acknowledged the disadvantage they face in treating mental health issues when the patient visit is limited to 20-30 minutes. Previously, physicians were forced to prioritize other medical problems above mental health issues, or a patient’s depression would not be brought up until the end of the visit, at which time the physician would not have the time to address it properly. The physicians explained it would be helpful to know a patient was having depressive symptoms before they entered the room, so they could preemptively discuss solutions with social workers and nurses and prioritize discussion of mental health with the patient. With the standardized screening and recording of the depression scores in the EMR, the collaborative care model provides physicians with adequate notice of when their patients are experiencing depressive symptoms that need to be addressed.
Another barrier to mental health care that staff have observed are the long waiting periods that patients experience when getting connected with psychiatry. Patients can wait several weeks before they can meet with someone from psychiatry and we found that physicians were less likely to refer a patient for psychiatric evaluation because of this waiting time. Instead they recommended that patients meet with social workers in clinic, who could usually meet with patients the same day. While social workers in the HIV clinic provide invaluable support and address many of the social factors affecting someone’s mental health, they do not perform diagnostic assessments or make treatment recommendations. The collaborative care model includes weekly case consultations between BHCs and a psychiatrist, which allows for timely review of a patient’s progress, recommendations for treatment augmentation, and, if necessary, a referral for a direct psychiatric evaluation.
Finally, the prevalence of addiction was a prominent barrier to treating mental health. All providers acknowledged addiction as an important problem that can negatively impact both a person’s mental and physical wellbeing. However, some physicians and nurses felt ill-equipped to identify addiction and expressed interest in trainings that would help familiarize them with common signs of substance use and addiction.