Page 1 of 1

Figure 4. A paradigm case formulation of collaborative care

A National Agenda for Research in Collaborative Care

  1. A team—
    1. A family physician, clinical psychologist, and care manager working together (along with other clinic staff):
      • T1. Change "family physician" discipline to any other physician discipline.
      • T2. Change "psychologist" discipline to any other mental health professional discipline.
      • T3. Delete "care manager."
    2. Working in the same space—within the spatial and operational limits of a particular primary care clinic:
      • T4. Change "limits of a particular primary care clinic" to "multiple clinics and clinical partners."
      • T5. Change "working in the same space..." to "a set of working relationships between collaborating clinicians in separate spaces that achieves communication, collaboration, two-way referrals and most other characteristics of on-site collaborative care."
    3. Having had formal or on the job training and preparation for the clinical roles and relationships of collaborative care (for both medical and behavioral clinicians):
      • There is no transformation. Clause 1C is necessary for a particular practice to claim it is doing "collaborative care."
    4. Working in one new practice culture rather than separate and parallel behavioral and medical practice cultures; able and eager to identify and deal with the biopsychosocial range of problems; substantive clinical roles and standing in the clinic for the behavioral clinicians:
      • T6. Change "single culture" to "recognition and commitment to continuing to build a shared single culture of care."
  2. With a shared population and mission—
    1. Identified with the same panel of clinic patients, under the same, shared mission of primary care, including assessment, treatment, and followup:
      • T7. Change "mission of primary care" to "mission and boundaries of any other specialty or area of medicine."
      • T8. Change "identified with same panel of clinic patients" to any identifiable subset of clinic pts for whom collaborative care is made available, e.g., an age group, disease cluster, other population.
    2. With the BH clinician also operating under the mission and scope of primary care, including mental health, behavioral health, and chemical dependency—recognizing the boundaries of primary care and the need for specialty mental health, just as primary care physicians know when they need medical specialists:
      • There is no transformation (except as carried forward in T7). Clause 2F is necessary.
  3. Using a clinical system—
    1. Employing a population-level screening method to identify who needs this collaboration.
      • T9. Change "population-level screening" to "identification system using epidemiological parameters, physician detection etc, based on system capabilities."
    2. Working from an explicit unified care plan document for each patient that contains assessments and plans for biological, psychological, and social aspects of the patient's health and healthcare; with team roles and goals—and how they are to be differentiated and integrated.
      • T10. Change "unified care plan document in a shared medical record" either to:
        1. "Clinical information in separate records unified through routinely updated letters, phone calls, or other documents and ongoing clinician communication" or
        2. "The problem list and shared plans are contained in provider notes or other records in the same organizational medical record which everyone reads and acts upon."
    3. With care plans that pay attention to the systems in which the patient operates or has membership, e.g., family, culture, language, schools, vocational, community:
      • There is no transformation. Clause 3I is necessary for a practice to claim it is doing collaborative care.
    4. Contained in a shared medical record, with regular ongoing communication among team members and shared patient-clinician decisionmaking:
      • T11. Delete "patient-clinician decision-making" or broaden to include "patient/family-clinician..."
  4. Supported by an office practice and financial system—
    1. Clinic operational systems, office processes, and office management that supports communication, collaboration, and care management along with "traditional medicine," and that are as clear, effective, and efficient as can be found in primary care.
      • T12. Delete "office processes that are as clear, effective, and efficient as can be found."
    2. Sustainable financial model(s) that supports collaborative clinical work, such as A) single pot of insurance benefits for all care, B) traditional FFS, C) bundled care management fees or capitation-type arrangement, D) some form of pay for performance or quality bonuses, E) philanthropic grants:
      • T13. Delete or add any one or more modes of financial support as long as it still supports collaborative care operations.
      • T14. Substitute "working toward sustainability" for "sustainably", regarding financial support.
  5. And continuous quality improvement and effectiveness measurement.
    1. Routinely collecting and using practice data for quality improvement, changing what you are doing, or effectiveness research as a normal ongoing part of the clinical practice:
      • T15. Substitute "commitment and a proposal for routinely collecting and using practice data..." for: "routinely collecting and using practice data..."

Return to Document

Page last reviewed June 2011
Internet Citation: Figure 4. A paradigm case formulation of collaborative care: A National Agenda for Research in Collaborative Care. June 2011. Agency for Healthcare Research and Quality, Rockville, MD.