Integrating Behavioral Health with the IMPACT Model

Depression is a serious and costly health issue across older adult populations. Currently primary care settings deliver over 80 percent of mental health treatment; however, the IMPACT Care model, a type of collaborative treatment plan, can nearly double the effectiveness of standard depression treatment for patients.

The IMPACT Care model focuses on team collaboration with a shared care plan and patient-centered approach. This program includes initial options for antidepressants or problem-solving treatments, depending on the patient’s preference for types of depression treatment.

IMPACT, which stands for Improving Mood- Promoting Access to Collaborative Treatment, first started as one of the largest treatment trials for depression to date, led by Dr. Jurgen Unutzer and his team of researchers. Following 1,801 depressed, older adults from 18 diverse primary care clinics across the United States for two years, Unutzer studied the difference between Usual Care offered by primary care clinics and collaborative care provided through the IMPACT model.

What is Usual Care?

Usual Care refers to primary care or referrals to specialty mental health service, if available. Few older adults receive effective treatment, especially through this model of Usual Care, as fewer than 10% of depressed adults seek care from a mental health specialist. Furthermore, only one in five older adults treated for depression in primary care improve, which was reflected by the IMPACT trial results.

Challenges for treating depression within the primary care setting include limited time and competing priorities, limited follow-up on referrals, and a general limited access to mental health experts.

What is IMPACT Care?                     

The IMPACT Care model focuses on team collaboration with a shared care plan and patient-centered approach. This program includes initial options for antidepressants or problem-solving treatments, depending on the patient’s preference on types of depression treatment. Throughout the treatment process, the collaborative care team uses a “treat-to-target” approach, where care plans are adjusted based on clinical outcomes and individual patient results. Furthermore, there is a shared accountability for the patient’s outcome across all providers and stakeholders within the collaborative team.

Who is on the Collaborative Team?

In Usual Care, the depression treatment team typically consists of two members: the patient and the primary care provider. However, the IMPACT model provides two additional members to the treatment team: the care manager and the psychiatric consultant.

The Patient

IMPACT includes the patient as an active participant in his/her depression treatment, as patient involvement often results in patient empowerment, adherence, and satisfaction.

The Primary Care Provider

Most primary care providers are trained to make initial behavioral health assessments and treatment plans; however, many usually lack the time and skills to fully assess and treat a patient’s mental health problem.

In the IMPACT model, the primary care provider receives support and expert advice through collaboration with the care manager and the psychiatric consultant. While the primary care provider continues to oversee all aspects of his/her patient’s care, including prescriptions and referrals, the use of collaborative care encourages on-going follow-ups with patients and proactive adjustments in treatment plans.

A collaborative approach to behavioral health treatment is crucial because only 30-50% of patients have full response to their initial depression treatment. With the ability to consult and work with additional experts, primary care providers are able to work the 50-70% of patients who need an adjustment in their initial treatment plan.

The Care Manager

Coordinating the overall communication among team members, care managers are behavioral health professionals, including nurses, psychologists, social workers, or licensed counselors. Their role involves creating a plan for each member within the group and completing specialized behavioral health tasks, which may include offering psychotherapy if selected as part of the treatment plan. Other tasks include alerting the primary care provider when the patient is not improving, and supporting medication management.

The Psychiatric Consultant

The psychiatric consultant assists the primary care provider and the care manager in treating the patient and making adjustments to the treatment plan if the patient is not at least 50% improved after 10-12 weeks of the plan. While the consultant is an active member of the collaborative team, he/she does not usually see the patient in-person and does not prescribe medications. Instead, the consultant assists with the primary care team diagnosis and resulting treatment plans.

How Effective is IMPACT?

Other trials have also shown that a collaborative care approach is more effective than usual care, with results showing benefits within the field of depression treatment, as well as treatment for anxiety disorders, PTSD, and co-morbid medical conditions such as heart disease, diabetes and cancer.

The IMPACT model has more than doubled the effectiveness of depression treatment for older adults in primary care settings, effectively addressing the challenges of patient attitude and limited knowledge as well as the challenge of limited time and resources in a primary care setting. Results from the IMPACT trial reflected that collaborative care improved satisfaction with depression care, doubled the effectiveness of usual care for depression, lowered health care costs in some areas, and continued positive patient responses even up to a year after the treatment plan’s completion.

How Do You Implement IMPACT?

Implementing IMPACT is achieved through a five-step implementation guide offered by University of Washington, as IMPACT is a program of the University. While implementing IMPACT involves behavioral health practice changes on multiple levels, the results of the IMPACT trial reflects the effectiveness and necessity for such a program.

The IMPACT Care model is both effective and adaptive, addressing the personal goals of each collaborative team member and ultimately creating a treatment plan that respects both the preferences of the patient and the medical expertise of the care team.

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