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The Relevancy of Relevance--Collaborative Care's Search for Maturity

Posted By Ben Miller, Thursday, January 20, 2011
Updated: Friday, May 27, 2011

In the spirit and tradition of Albert Camus, let us take a moment and dwell in the absurd. Now for you philosophy majors out there, I am not going to attempt to do justice to true absurdist philosophy, but rather take great liberties and address the field of collaborative care. Camus believed that life was absurd in that human’s constantly seek meaning from life, but have difficulty finding it. Collaborative care as a field continues to search for meaning. The ultimate question is where can the field find that meaning and is it possible to obtain this meaning?

It has been shown for some time that integrating mental health into the larger medical arena leads to better outcomes. While research of this type initially began in specialty medical settings, it has more recently expanded into the general healthcare arena, primary care. As where most people receive their healthcare, primary care identifies more mental health, treats more mental health, and arguably has the most to do with what happens "next” with mental health than the mental health system. Still, in the face of these facts, there remains difficulty integrating mental health providers into primary care to "streamline” and "defragment” how we as a healthcare system treat mental health. This fundamentally is a policy issue, and one that has not been tackled.

As I have recently charged the field to do more work in the policy domain for collaborative care (see upcoming Families, Systems & Health issue), I will not do so here; however, I want to make the point that much discussion and effort for collaborative care should continue to include policy whenever possible.

So conceptually, most agree that by integrating we are doing a great service to patients who would benefit from these services. We have some research, wonderful stories, and passionate leaders, but we do not have a firm standing in the healthcare system whereby our efforts are discussed as often as other "left out” aspects of healthcare such as prevention, quality measures and enhanced/modified payment schemes. So how relevant is collaborative care? How mature is the field? I will argue that there needs to be a tri-fold process that occurs to lead collaborative care down a road of increased relevancy and maturity especially as it relates to policy.

  1. Disruptive Innovation: Each new integration effort, started, studied and written up should do so under the auspices that the content can disrupt the status quo and attempt to address second order change. Papers simply rehashing what we know may not be that helpful for moving collaborative care forward; no more reviews of how great integration is – we have plenty of these. We need disruptive research and innovation that can move the "needle” for collaborative care.
  2. Policy Briefs: Sites interested and actively engaged in integration should become experts on how to write up one-page policy briefs. While stories have a powerful impact on policy, concise one page policy briefs that highlight an issue on integration with data (qualitative or quantitative) can be an even more powerful and persuasive argument for policy makers. One-page policy briefs, as difficult as they are to write, and write well, will be a distinguishing characteristic of a mature field where newly learned information begins to be included in the national dialogue on healthcare (for example of excellent one pagers see here). Additionally, policy briefs can accomplish the goal of getting the community talking about an issue germane to collaborative healthcare and bring the field more closely together.
  3. Seeing the Big Picture: Representing an ideal, a whole (field/movement), rather than a specific part (my model) means that rapid infusion of the collaborative care message into policy may be more likely as fewer barriers will be in place filtering the message. Policies advocating for comprehensive collaborative healthcare can be inclusive. Since there is much we still need to know about what strategies work for integration, it is premature to promote a "standard approach” to integration. However, by grounding our argument in the inseparability of mental from physical, we can discuss the cost of separating mental and physical, the problem with access to mental health, and providers desire to have onsite mental health, we can start to address the "big picture” not simply another workaround.

So you see, collaborative care has a way to go before we can increase our stage presence on the national healthcare stage. We can get there faster if we begin to consider how to mature our field by more comprehensively studying our disruptive integration efforts, writing up smart, concise policy briefs on said efforts, and recognize collaborative care’s role in the larger healthcare system.

Is it possible to find our "meaning” as a field or will we continue to search for meaning without ever finding it? Addressing policy head on is a proactive way to find our meaning for collaborative care. Because really, the last thing any of us want is for collaborative care to be a "stranger” in national healthcare debates.

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Cheryl Holt says...
Posted Friday, July 8, 2011
Thank you for this thought-provoking commentary.

While enthusiasm, energy, and the current momentum building in the behavioral health and primary care communities is a great start, it lacks the power to drive this issue forward to have the impact necessary for the changes required. I agree that taking a big picture view is necessary for effectively impacting policy. One such area that must be addressed is the overarching issue of merging disparate cultures. This “soft” issue is frequently overlooked or deemed unworthy of attention in lieu of more tangible issues such as coding, billing, governance, etc.

There are numerous inefficiencies in healthcare today. Specialty care and primary care often do not play well together due to the alarming lack of communication. This frequently leads to excessive duplication of efforts, such as labs and other diagnostic procedures. Collaborative care addresses this problem. It also helps to bridge the culture gap evidenced in the disparate settings.

However, there are inefficiencies within primary care as well. A trip to the PCP will often result in three healthcare professionals asking the patient for the same information. Ineffective methods of communication exist within many clinics. Electronic health records help but do not solve this issue.

A focus on developing the relationship between healthcare providers providing collaborative care is vital to avoiding duplicative, or even worse, contradictory efforts, in treating the patient. This includes frequent communication, respect for the different cultures among the specialties, and a willingness to compromise, to name a few. Unfortunately, this does not come natural to most. It requires time, patience, and understanding. Too many promising collaborative partnerships have failed due to such issues.
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Randall Reitz says...
Posted Friday, July 8, 2011
Ben, I woke up early to get some work done, but then spent over an hour cruising your links--a treasure-field. My favorite was the New Yorker piece on the shortcomings of the current scientific method ("It's as if our facts were losing their truth.")

For me, this is the biggest obstacle facing collaborative care. We are an inter-disciplinary group that doesn't advance any one guild or have a product to sell. As such, there is far less impetus to carry out the large RCT's which would support our model. If we can only rely on the publishing energy of altruistic scientists like yourself, then we will struggle in anonymity for years to come before we can effectively make a research-based case.
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