Collaborative Care Models for Behavioral Healthcare Services Integration

Abstract

Despite the widespread evidence of the effectiveness of integrated behavioral healthcare interventions at improving health outcomes, particularly among patients with comorbid chronic illnesses, their adoption into primary care delivery settings remains slow. This study evaluates the Collaborative Care Model, an evidence-based integrated behavioral healthcare intervention, in two different implementation contexts: a low-barrier HIV clinic in Seattle, Washington where care for depression and opioid use disorder was integrated into primary care, and four urban diabetes clinics in India where care for depression was integrated into diabetes care. The study had three distinct aims: to elicit the anticipated barriers and facilitators to implementing the Collaborative Care Model in low-barrier HIV care, to evaluate the acceptability and feasibility of the Collaborative Care Model in low-barrier HIV care, and to conduct a mediation analysisevaluating the effect of change in self-stigma on diabetes outcomes as mediated by depression symptom severity in urban diabetes care in India. We found that while the patients and stakeholders at a low-barrier HIV clinic were receptive to implementing the Collaborative Care Model, they identified as barriers the availability of resources in the inner implementation setting; practical concerns about the perceived contextual fit with low-barrier HIV care; and its anticipated suitability due to the burden of other behavioral health comorbidities and complete socio-economic needs. The Collaborative Care Model was acceptable and feasible to implement in a low-barrier HIV clinic but only with key adaptations to core interventions to improve its contextual fit. Of the 175 eligible patients, 36% of were screened, 24% were referred, 15% completed an intake, and 9% progressed to the engaged step of the care cascade. Whereas logistical challenges in the inner implementation setting and staff perceptions of its feasibility hindered patient progression through the care cascade from screening through engagement, the Behavioral Health Care Manager’s ability to exemplify the clinic’s values and culture, qualities underscoring patient satisfaction, facilitated patient progression through the care cascade. Depressive symptoms did not mediate the effect of change in self-stigma on diabetes outcomes and self-stigma scores did not vary longitudinally comparing patients being treated for depression via the Collaborative Care Model to enhanced standard of care in urban diabetes clinics in India.