The Washington State Mental Health Integration Program (MHIP)
The Washington State Mental Health Integration Program (MHIP) was created in 2007 in partnership between the Community Health Plan of Washington (CHPW, a not-for-profit health plan), Seattle-King County Department of Public Health, and the AIMS Center at the University of Washington. The program was initially piloted in two of Washington State’s most populous counties. Program data from the first years of 2008 and 2009 showed that, compared to counties without MHIP, the target population in MHIP counties experienced:
- 17% fewer inpatient medical admissions and smaller increases in inpatient psychiatric costs (21% vs. 167%) over the review period.
- 24% decline in the number of arrests
- Smaller increase in those living in homeless shelters or outdoors (50% vs. 100%)
- Smaller increase in days spent in state hospitals (33% vs. 500%)
The RESPECT-Mil program (Re-Engineering Systems of Primary Care Treatment of PTSD and Depression in the Military) is an Army-wide, Collaborative Care initiative aimed at improving the primary care system’s capacity to identify and effectively treat service members with depression and posttraumatic stress disorder (PTSD) within the military health system (MHS) (Wong et al. 2015).
The RESPECT-Mil program served as the precursor to the currently existing Collaborative Care Patient-Centered Medical Home (PCMH) model now implemented for all beneficiaries across Army, Navy, and Air Force primary care clinics. Before transitioning to the second-generation military health systems PCMH approach, RESPECT-Mil was implemented for over 3.5 million visits in 94 primary care clinics located at 39 installations and eight time zones worldwide. In addition, RESPECT-Mil led to the first large multisite randomized controlled trial of a health care delivery intervention in the MHS, the STEPS-UP Trial (STepped Enhancement of PTSD Services Using Primary Care), a trial evaluating Collaborative Care implementation approaches for PTSD and depression (C. C. Engel et al. 2014; C. Engel et al. 2015). The trial is nearing completion.
Veterans Health Administration (VHA)
The Veterans Health Administration (VHA) has the most extensive experience with Collaborative Care implementation in the United States. They are in the process of implementing the Primary Care-Mental Health Integration (PC-MHI) in over 7,000 primary care clinics (Reid and Wagner 2014). In 2010, the VHA began to augment primary care teams to ensure at least four full-time health care professionals per panel of primary care patients, including mental health professionals, nutritionists, and clinical pharmacy specialists. Organization-wide metrics provide accountability and visibility for opportunities to standardize and improve access and care.
PC-MHI blends two models of integrated care:
- The Collaborative Care Model (referred to as care management)
- The Behavioral Health Consultant Model (referred to as co-located care) (Dundon and Dollar 2011)
All VA Medical Centers and Community-Based Outpatient Clinics (CBOCs) with more than 5,000 patients are required to implement both models. The requirement for a blended model is based on the evidence base of the Collaborative Care, and the need for co-located mental health specialists to provide immediate access for patients. Collaborative Care is designed to support PCPs prescribing of psychotropic medications and includes proactive longitudinal follow-up and brief behavioral health interventions. Collaborative Care services are usually provided over the telephone, often by staff who are not independently licensed but who are supervised by a psychiatrist or psychiatric advance practice nurse. Co-located behavioral health consultants conduct curbside consultations with PCPs and participate in interdisciplinary team huddles.