Team-based stepped care in integrated delivery settings

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Abstract

Fragmented health care delivery is recognized as increasingly problematic. Integrated care has been advanced as a reform that will improve quality of care and lower costs. Despite the application of integrated care systems in the United States, there has been a limited amount of empirical work explicating the most effective health care pathways. Stepped care has been proposed as a framework by which to implement coordinated team-based care and has gained preliminary empirical support. In this manuscript a rationale for team-based stepped care is presented, tools for implementation are provided, and future research directions are suggested.

Most cited references 20

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Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial.

E J Ludman, Kevin Bush, J Unützer … (1999)

Despite improvements in the accuracy of diagnosing depression and use of medications with fewer side effects, many patients treated with antidepressant medications by primary care physicians have persistent symptoms. A group of 228 patients recognized as depressed by their primary care physicians and given antidepressant medication who had either 4 or more persistent major depressive symptoms or a score of 1.5 or more on the Hopkins Symptom Checklist depression items at 6 to 8 weeks were randomized to a collaborative care intervention (n = 114) or usual care (n = 114) by the primary care physician. Patients in the intervention group received enhanced education and increased frequency of visits by a psychiatrist working with the primary care physician to improve pharmacologic treatment. Follow-up assessments were completed at 1, 3, and 6 months by a telephone survey team blinded to randomization status. Those in the intervention group had significantly greater adherence to adequate dosage of medication for 90 days or more and were more likely to rate the quality of care they received for depression as good to excellent compared with usual care controls. Intervention patients showed a significantly greater decrease compared with usual care controls in severity of depressive symptoms over time and were more likely to have fully recovered at 3 and 6 months. A multifaceted program targeted to patients whose depressive symptoms persisted 6 to 8 weeks after initiation of antidepressant medication by their primary care physician was found to significantly improve adherence to antidepressants, satisfaction with care, and depressive outcomes compared with usual care.

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Integrating mental health and primary care services in the Department of Veterans Affairs health care system.

Bradley Karlin, Dinah M Zeiss (2008)

Integrating mental health care in the primary care setting has been identified in the literature as a model for increasing access to mental health services and has been associated with enhanced clinical and functional patient outcomes and higher patient satisfaction. The Department of Veterans Affairs (VA), which operates the nation's largest integrated health care system, has taken a leadership role in creating a health care system in which mental health care is provided in the primary care setting. This article examines VA's efforts and progress to date in implementing evidence-based models of integrated mental health services nationally in community based outpatient clinics, home based primary care, and outpatient primary clinics at medical facilities. Psychology plays an important role in this progress, as part of an overall interdisciplinary effort, in which all professions are crucially important and work together to promote the overall well-being of patients.