The Collaborative Care Model: Strength in Unity

By: Stephanie Beldick

Medical specialties are currently structured to provide patients with specialized care within a focused healthcare arena, leading to the compartmentalization of responsibility between different physicians. Targeting this fragmentation, collaboration amongst specialists is becoming increasingly recognized as the solution. However, to date, there has been limited adoption across the country, especially in smaller centres. As a result, this article seeks to explore the benefits and caveats of collaborative care as well as the challenges in its implementation into medical practice and the Canadian healthcare system.

Through the timely cooperation and teamwork of multiple healthcare specialists, collaborative care aims to provide population-based and patient-centered treatment. In Ontario, this usually takes its form through letters of communication between a patient’s primary care physician and the specialists to whom they are referred. Yet, with a rise in multiple chronic comorbidities and an aging population, there is a need for large-scale implementation of integrated care. Importantly, large institutes, such as the University Health Network, which have the capacity to implement this approach, have made strides towards collaboration, specifically by establishing polyclinics. Similarly, telemedicine is also gaining popularity for cross-centre care. Nevertheless, despite the success, these strategies remain largely absent in most community settings across the country.

Numerous clinical trials have shown the effectiveness of the collaborative care model.¹ Chronic conditions, such as cancer, diabetes, and vascular diseases provide poignant examples of the instrumental role of this approach. As these conditions are frequently associated with depression and anxiety that worsen patient outcomes, there are striking improvements when primary care providers work closely with teams of nurses, social workers, and psychiatrists.^2-3 Not only does the collaborative care model positively impact health outcomes, but it also reduces long-term healthcare costs. Patients with diabetes and/or coronary heart disease with comorbid depression benefit from more depression-free days and an increased number of quality-adjusted life years (QALYs) when an ongoing rapport with a nurse care manager is maintained.⁴ Moreover, given that sustained depression in this cohort of patients has been shown to lead to vascular complications and dementia, the collaborative care model is also cost-effective beyond the time of intervention.⁴

Acknowledging the benefits of collaborative, patient-centred care to patients and communities, medical teaching centres are at the forefront of implementing this model. These innovative centres practice a holistic and unified approach to teaching communication and teamwork. An excellent example is the St. Michael’s Family Health Team, which consists of multiple healthcare specialists, including physicians, chiropractors, psychologists, and acupuncturists.^5-6 Together, this strategy provides a platform through which patients benefit from comprehensive care, in addition to training healthcare providers to be members of an interdisciplinary team.

The benefits of the collaborative care model are not, however, ubiquitous. One randomized trial sought to implement the model to improve outcomes in patients with childhood asthma, but failed to show a significant difference between the collaborative care model and the standard care group. The authors suggested that the nonsignificant result could stem from insufficient participation in workshops by patients and families, along with various other site-specific and administrative discrepancies.⁷ Similarly, a study by Katon et al. (2012) showed that comorbid depression was reduced in patients with diabetes and/or coronary heart disease, while other clinical measures such as hemoglobin A_1C, systolic blood pressure, and low-density lipoprotein cholesterol levels did not differ between the groups after 12 months. ⁴ While these studies’ findings indicate that the collaborative care model is not universally beneficial across all health outcome measures, it has been shown as an overall effective approach at reducing healthcare costs and improving patient quality of life.^2,8-9

Indeed, there are barriers to promoting a broader implementation of the collaborative care model. Added short-term costs can create an economic burden on the public healthcare system, as demonstrated in a study from Johnson et al. (2016) that assessed the cost-effectiveness of collaborative care in patients with depression and type 2 diabetes. However, the increase in short-term costs was compensated for by the increase in QALYs that resulted from team-based monitoring and increased follow-up care.¹⁰ The way that the model is implemented across centres may present another hurdle, thereby limiting the efficacy. Governmental resources to support the programs will need to be allocated appropriately and consistently in order to establish structured and successful collaborative care models.

Canada is certainly on its way toward a universal collaborative care model, however, there is still some work to be done. As a community, we need to continue supporting this approach by encouraging its continued incorporation into healthcare education and funding programs that will help to make it easier for current clinicians to participate in team-based practice. Potential benefits of the collaborative care model are the long-term cost-effectiveness and improved health outcomes, which are enhanced through communication among various specialists, access to holistic care, and encouraging patients to take an active role in their own care. It is evident that the collaborative care model is strengthening medical practice and patient care, and while the Canadian medicine has taken steps toward a more unified system, improvements to implementation will be necessary.

References

1. Summers RF. Integrated behavioral health care and psychiatric training. Academic Psychiatry. 2015 Aug 1;39(4):425-9.
2. Ivbijaro GO, Enum Y, Khan AA, et al. Collaborative care: models for treatment of patients with complex medical-psychiatric conditions. Current psychiatry reports. 2014 Nov 1;16(11):506.
3. Huffman JC, Mastromauro CA, Beach SR, et al. Collaborative care for depression and anxiety disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized clinical trial. JAMA internal medicine. 2014 Jun 1;174(6):927-35.
4. Katon W, Russo J, Lin EH, Schmittdiel J, Ciechanowski P, Ludman E, Peterson D, Young B, Von Korff M. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. Archives of general psychiatry. 2012 May 1;69(5):506-14.
5. Innovative program at St. Mike’s integrates chiropractic care. Hospital News, cited 2017 Oct 6. Available from: http://hospitalnews.com/innovative-program-at-st-mikes-integrates-chiropractic-care/
6. Koehler St. Michael’s chosen by WHO as example of integrated and people-centred health care. St. Michael’s Newsroom, 2016 June 3, cited 2017 Oct 6. Available from http://www.stmichaelshospital.com/media/detail.php?source=hospital_news/2016/0603a
7. Homer CJ, Forbes P, Horvitz L, et al. Impact of a quality improvement program on care and outcomes for children with asthma. Archives of pediatrics & adolescent medicine. 2005 May 1;159(5):464-9.
8. Duarte A, Walker J, Walker S, et al. Cost-effectiveness of integrated collaborative care for comorbid major depression in patients with cancer. Journal of psychosomatic research. 2015 Dec 31;79(6):465-70
9. Sockalingam, S., Mulsant, B. H., & Mylopoulos, M. (2016). Beyond integrated care competencies: The imperative for adaptive expertise. General hospital psychiatry, 43, 30-31.
10. Johnson JA, Lier DA, Soprovich A, Al Sayah F, Qiu W, Majumdar SR. Cost-Effectiveness Evaluation of Collaborative Care for Diabetes and Depression in Primary Care. American journal of preventive medicine. 2016 Jul 31;51(1):e13-20.