Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health
Authors: Mark S. Bauer, Christopher J. Miller, Bo Kim, Robert Lew, Kelly Stolzmann, Jennifer Sullivan, Rachel Riendeau, Jeffery Pitcock, Alicia Williamson, Samantha Connolly, A. Rani Elwy, Kendra Weaver
Journal: JAMA Network Open (2019)

IMPORTANCECollaborative chronic care models (CCMs) have extensive randomized clinical trial evidence for effectiveness in serious mental illnesses, but little evidence exists regarding their feasibility or effect in typical practice conditions.OBJECTIVE To determine the effectiveness of implementation facilitation in establishing the CCM in mental health teams and the impact on health outcomes of team-treated individuals. DESIGN, SETTING, AND PARTICIPANTSThis quasi-experimental, randomized stepped-wedge implementation trial was conducted from February 2016 through February 2018, in partnership with the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention.Nine facilities were enrolled from all VA facilities in the United States to receive CCM implementation support.All veterans (n = 5596) treated by designated outpatient general mental health teams were included for hospitalization analyses, and a randomly selected sample (n = 1050) was identified for health status interviews.Individuals with dementia were excluded.Clinicians (n = 62) at the facilities were surveyed, and site process summaries were rated for concordance with the CCM process.The CCM implementation start time was randomly assigned across 3 waves.Data analysis of this evaluable population was performed from June to September 2018.INTERVENTIONS Internal-external facilitation, combining a study-funded external facilitator and a facility-funded internal facilitator working with a designated team for 1 year. MAIN OUTCOMES AND MEASURESFacilitation was hypothesized to be associated with improvements in both implementation and intervention outcomes (hybrid type II trial).Implementation outcomes included the clinician Team Development Measure (TDM) and proportion of CCM-concordant team care processes.The study was powered for the primary health outcome, mental component score (MCS).Hospitalization rate was derived from administrative data. RESULTSThe veteran population (n = 5596) included 881 women (15.7%), and the mean (SD) age was 52.2 (14.5) years.The interviewed sample (n = 1050) was similar but was oversampled for women (n = 210 [20.0%]).Facilitation was associated with improvements in TDM subscales for role clarity (53.4%-68.6%;δ = 15.3;95% CI, 4.4-26.2;P = .01)and team primacy (50.0%-68.6%;δ = 18.6; 95% CI, 8.3-28.9;P = .001).The percentage of CCM-concordant processes achieved varied, ranging from 44% to 89%.No improvement was seen in veteran self-ratings, including the primary outcome.In post hoc analyses, MCS improved in veterans with 3 or more treated mental health (continued) Key Points Question Collaborative chronic care models for mental health conditions are supported by extensive randomized clinical trial data, but what is the evidence that these models can be implemented and can have beneficial effects in general clinical settings?Findings In this randomized clinical implementation trial of 5596 veterans, a collaborative chronic care model was shown to be effectively implemented with practical, scalable facilitation support for clinicians.Effects on selfreported health outcomes were limited, but mental health hospitalization rate improved.Meaning These findings suggest that collaborative chronic care models can be exported to general clinical practice settings using implementation facilitation and, at least for individuals with complex mental health conditions, can improve health outcomes.