A Learning Health System Conceptual Framework to Guide Implementation and Sustainability of the Collaborative Care Model in Community-Based Mental Health Settings

Abstract

Individuals with a serious mental illness (SMI) diagnosis often experience poor physical health outcomes and low-quality care. They also have high mortality and premature mortality rates due to natural causes, specifically cardiovascular disease (CVD being the number one cause. Despite the advancements in evidence-based practice (EBP) to treat CVD, these advancements do not benefit the SMI population leading to disparities. To address the disparities among this population requires an integrated approach to care, however, the delivery of care to this population is complex. Since a large portion of this population seeks care in community mental health settings (CMHs) and these settings receive policy-level to support the integration of physical and behavioral health services, this is an opportunity to implement evidence-based integrated models. It is not well understood how to effectively implement integrated EBPs, like the Collaborative Care Model (CCM), which has been shown to be effective to improve health outcomes in the SMI population. The purpose of this study is to provide a comprehensive description of how CMHs organizational context can influence the implementation and sustainment of a CCM designed to address physical health issues, specifically CVD risk factors. To accomplish this, I used a mixed methods study design, using quantitative and qualitative data to evaluate CMH organizations. I initially evaluated CMHs constructs known to impact effective implementation of EBP using three validated tools, the Implementation Climate Scale (ICS), Implementation Leadership Scale (ILS), and Organizational Readiness for Change Context subscale (ORCA), while determining if they impact the use of EBPs in CMHs. Then, I used the Consolidated Framework for Implementation Research 2.0 (CFIR 2.0) to analyze stakeholders’ perspectives of the process relevant to address the SMI populations’ physical health and identify barriers and facilitators to a CCM, while identifying the health information technology (HIT) built within CMHs support the delivery of care used by these stakeholders. From there, in reviewing state Medicaid data, I was able to investigate the utilization of services among the SMI population seeking care across Michigan CMHs. The results show that Michigan CMHs have a moderate ICS, but a high ILS, and ORCA Context subscale. However, these constructs known to impact implementation of EBP do not have impact on the use of EBPs in CMHs. While barriers to characteristics of a CCM exist in CMHs, these barriers are influenced by partnerships and connections with external stakeholders, limited interoperability in the information technology structure, the culture focused on recipients, access to knowledge and training for front line providers, and knowledge of physical health among front line providers. I found that the HIT tools built across the CMHs align with the components of a CCM to optimize delivery of care, which can improve CMHs ability to overcome the barriers to implement and sustain a CCM. However, the utilization of health services outside of these settings among the SMI population seeking care in CMHs illuminates evidence for the need to improve coordination of care to address physical health. After evaluating CMH organizations, the utilization of a learning health system approach can serve as the conceptual framework to guide implementation of a CCM to improve the quality of care delivered to address physical health outcomes among the SMI population.