Collaborative Chronic Care Model Improved Patient Outcomes in Complex Mental Health Patients Interview with:

Mark S. Bauer, M.D.Professor of Psychiatry, EmeritusHarvard Medical SchoolCenter for Healthcare Organization and Implementation Research (CHOIR)VA Boston Healthcare System-152MBoston, MA 02130

Dr. Bauer

Mark S. Bauer, M.D.
Professor of Psychiatry, Emeritus
Harvard Medical School
Center for Healthcare Organization and Implementation Research
VA Boston Healthcare System-152M
Boston, MA 02130 What is the background for this study? What are the main findings? 

Response: Collaborative Chronic Care Models (CCMs) have extensive evidence for their effectiveness in a wide variety of mental health conditions.  CCMs are frameworks of care that include several or all of the following six elements:  work role redesign for anticipatory, continuous care; self-management support for individuals in treatment; provider decision support; information system support for population-based and measurement-guided care; linkage to community resources; and organization and leadership support.

However, evidence for Collaborative Chronic Care Model effectiveness comes almost exclusively from highly structured clinical trials.  Little is known about whether CCMs can be implemented in general clinical practice settings, and the implementation evidence that does exist derives primarily from studies of the CCM used in primary care settings to treat depression.

We conducted a randomized, stepped wedge implementation trial using implementation facilitation to establish CCMs in general mental health teams in nine US Department of Veterans Affairs medical centers.

We found that establishing Collaborative Chronic Care Models was associated with reduced mental health hospitalization rates and, for individuals with complex clinical presentations, improvements in mental health status.  Additionally, standardized assessment of team clinicians indicated that facilitation improved clinician role clarity and increased focus on team goals. What should readers take away from your report?

Response: Collaborative Chronic Care Model-based teams can reduce hospitalization rates and, for individuals with complex clinical presentations, improve mental health status. What recommendations do you have for future research as a result of this work?

Response: This implementation trial engaged nine sites.  Scaling up and spreading this approach to implementing Collaborative Chronic Care Models more broadly is the next logical step.

Disclosures: Dr. Bauer receives a small amount of royalties for books on CCM components.


Bauer MS, Miller CJ, Kim B, et al. Effectiveness of Implementing a Collaborative Chronic Care Model for Clinician Teams on Patient Outcomes and Health Status in Mental Health: A Randomized Clinical Trial. JAMA Netw Open. 2019;2(3):e190230. doi:10.1001/jamanetworkopen.2019.0230


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