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. Author manuscript; available in PMC: 2023 Dec 13.
Published in final edited form as: Proc ACM Hum Comput Interact. 2023 Oct 4;7(CSCW2):302. doi: 10.1145/3610093

“Our Job is to be so Temporary”: Designing Digital Tools that Meet the Needs of Care Managers and their Patients with Mental Health Concerns

RACHEL KORNFIELD 1, EMILY G LATTIE 2, JENNIFER NICHOLAS 3, ASHLEY A KNAPP 4, DAVID C MOHR 5, MADHU REDDY 6
PMCID: PMC10718568  NIHMSID: NIHMS1949487  PMID: 38094872

Abstract

Digital tools have potential to support collaborative management of mental health conditions, but we need to better understand how to integrate them in routine healthcare, particularly for patients with both physical and mental health needs. We therefore conducted interviews and design workshops with 1) a group of care managers who support patients with complex health needs, and 2) their patients whose health needs include mental health concerns. We investigate both groups’ views of potential applications of digital tools within care management. Findings suggest that care managers felt underprepared to play an ongoing role in addressing mental health issues and had concerns about the burden and ambiguity of providing support through new digital channels. In contrast, patients envisioned benefiting from ongoing mental health support from care managers, including support in using digital tools. Patients’ and care managers’ needs may diverge such that meeting both through the same tools presents a significant challenge. We discuss how successful design and integration of digital tools into care management would require reconceptualizing these professionals’ roles in mental health support.

Keywords: digital health interventions, mental health, healthcare systems, integrated care

1. INTRODUCTION

Mental health conditions are extremely common, with major depression and anxiety disorders annually affecting approximately 8.4% and 19.1% of the US adult population, respectively [73,74]. These conditions have profound consequences for individuals and society, impacting quality of life, wellbeing, healthcare costs, and participation in social activities, education, and the workforce [28,31]. Mental health conditions also frequently co-occur with physical health conditions [69,81,107], and these conditions can interact with and complicate one another [4,97]. Despite evidence that mental health treatment can reduce symptoms and improve wellbeing [20], individuals regularly face barriers to accessing care or receive inadequate care [66].

In the US, one barrier to delivering high quality mental health treatment at scale is a longstanding division between the mental health care system and broader health care system, reflecting a range of cultural, historical, and regulatory factors [45,101]. Because of this division, health care workers who are not mental health specialists may have limited training in delivering mental health treatment, few opportunities to collaborate with mental health specialists, and inadequate incentives to address mental health [23,105]. For instance, while primary care is where mental health care is most often sought [30,37], primary care physicians are not as well-trained in managing mental health conditions, and treatment quality and patient outcomes tend to be poor [105,119]. In recent years, there is a growing movement to integrate mental health into the broader care system [61], including through augmenting mental health treatment competencies in non-mental health specialists [22,93], adopting team-based interdisciplinary collaborative care models [29,117], improving measurement of mental health outcomes [54], and supporting patients in navigating the care system to meet complex health needs [24,121]. This includes the development of a range of “care management” and “care coordination” programs offering a central contact for patients, e.g., a “care manager” (or “care coordinator”) who is tasked with helping patients meet both their mental and physical health needs [49].

Concurrent with the increasing emphasis on integrated care, digital mental health (DMH) tools have emerged over the past decade as a promising way to expand and improve routine mental health care. Through ubiquitous digital devices like computers, mobile phones, and wearables, DMH tools can offer patients ongoing access to information, support, and resources for managing their mental health concerns. When deployed within the healthcare system, such tools have potential to help in remote patient monitoring, decision-making around treatment, coordination between providers, and ongoing communication with patients [12,39,112]. Yet, while DMH tools have helped reduce patients’ symptoms in clinical trials, few have been successfully integrated into healthcare settings [108]. This reflects factors including 1) limited engagement of less motivated patients in the design process, leading to tools that many patients are unwilling to use in day-to-day life, and 2) failures to consider how these tools fit within varied contexts and workflows in clinical practice settings [67]. A particular challenge is finding scalable ways to offer the ongoing human support that underlies many effective digital tools [64,65], and to fit these activities into workflows that are already highly busy and complex. If technologies are integrated without consideration of effects for caregivers, they risk having low uptake, contributing to burnout, or producing other unintended consequences [33,56,67,82].

For digital tools to improve management of mental health in the health system requires understanding both patients’ and healthcare workers’ roles in managing mental health, and their envisioned uses of technology in the process [67,86]. CSCW can play a valuable role here, with recent work in the field speaking to ways that DMH tools support day-to-day collaborative practices to support mental health [13,14]. CSCW research has explored how individuals solicit and provide peer-to-peer support through social media and online forums [2,7,76,83,126], and how technologies can help support givers play a long-term role in patients’ mental health management, including informal caregivers like friends and family [13,14,102,123], peers [78,79], and mental healthcare providers [59]. However, this work has not yet explored how technologies can support the work of non-mental health specialists in the health care system, like care managers. To provide mental health services for those who need them, and to provide more coordinated care, non-specialists are increasingly involved in mental health care and have been proposed as potential front line implementers of DMH tools [18,24,49,64], but little is known about how they envision using technologies in their work.

To inform the design and use of DMH tools in the context of non-mental health specialists’ work, this study focuses on a group of care managers tasked with helping patients navigate the health system to meet their diverse needs involving mental and physical health. Although mental health concerns are common in patients served by care management programs, most care managers’ training and experience has primarily focused on physical health conditions. Expectations of the care manager role have started to encompass helping patients with their mental health concerns, but past research suggests that care managers deal with ambiguity in their changing role [49]. We know little about whether and how care managers see DMH tools playing a role in how they support patients’ mental health needs, or how their perspectives align with those of patients.

Our findings suggest that patients are interested in obtaining ongoing mental health support from care managers, including guidance in using DMH tools and accessing technology-mediated support for self-management. On the other hand, care managers saw their role largely as conducting initial assessments of patients and connecting them to providers for ongoing mental health support. While recognizing that limited availability of services often prevented patients from accessing timely care, care managers questioned whether their workload and training allowed them to play the role patients envisioned. Care managers saw potential value in patients’ independent use of DMH tools but had concerns about personally monitoring new data streams and communicating through channels that lack established norms and boundaries. We propose that differing views of care managers’ role need to be reconciled, and adequate training provided, if care managers play a larger role in mental health, and if DMH tools are integrated into care management. We also discuss ways that DMH tools might be designed to meet and balance both groups’ needs.

The paper is organized in the following way. In the next section, we discuss the related work that guided this investigation. In Section 3, we lay out the methods we employed. In Section 4, we discuss our findings. Finally, we discuss the implications of this work in Section 5.

2. RELATED WORK

In the following sections, we situate our investigation in relation to literature on the place of mental health within the healthcare system, the emergence of technology-enabled mental health services, and the ways support givers may use and benefit from DMH tools.

2.1. Integration of Mental Health within the Broader Care System

Mental health conditions and physical health conditions are often co-morbid [69,81,107], and can be mutually reinforcing [4,97]. This might manifest, for example, in depression symptoms interfering with self-management activities like exercise and healthy eating that are important in preventing and controlling conditions like cardiovascular disease and diabetes, or when anxiety interferes with seeking regular preventive care. Similarly, physical ill-health can exacerbate or complicate mental health, as when physical symptoms and loss of function worsen depression or anxiety symptoms. Care of simultaneous mental and physical health challenges is complex, often requiring a high level of coordination of services in the health system as well as an array of self-management activities [17,84,97]. Those patients who have a physical health condition that co-occurs with a mental health condition or substance use disorder have healthcare costs 2 to 3 times those with only physical health conditions [62], and make up a disproportionate fraction of “super-users” in the healthcare system, the approximately 5% of patients who consume about half of all health services [38]. Given the complexity and cost of managing both physical and mental health concerns, these patients represent a priority for healthcare interventions seeking to provide more efficient, affordable, and integrated care [15,62].

Recognizing that physical and mental health are fundamentally linked, collaborative care approaches seek to address both sets of needs. Approaches typically involve multidisciplinary care teams that work together to provide mental health care for patients, often in primary care [29,84]. Such programs have been adopted in settings including the Veterans Administration [34]. Across various settings, they have shown success in improving the quality of healthcare delivered to the patient, while also reducing healthcare costs by helping patients with chronic or complex health conditions manage their health [11,106]. Approaches can also involve assigning a care manager as a central contact for patients who have difficulty managing their healthcare, including those with both mental/behavioral and physical conditions. In these programs, a care manager assesses their patients to develop a full picture of needs and then has regular follow up aimed at helping patients navigate the care system to better meet those needs. Care managers are typically nurses or social workers by training who assist patients by coordinating medical care and providing education around symptom self-management [11].

However, care managers face a variety of challenges in their work around mental health, due to a lack of training in supporting patients’ mental health and a lack of readily available mental health resources in many healthcare systems [42]. These challenges may manifest in unwillingness to engage in mental health related conversations with patients, or lack of knowledge of the tools available to support the mental health needs of patients [49]. This is problematic for patients in care management programs, as depression is more common among adults with chronic medical conditions [95], a strong contributor to health-related disability [63], and associated with a worse prognosis in chronic conditions such as diabetes and cardiovascular disease [43,72].

As the next section describes, technologies are increasingly applied to efficiently and effectively address patients’ mental health, and may have a role to play in care management.

2.2. Technology-Enabled Mental Health Services

DMH tools have received increasing attention over the past two decades [104,114], and especially since the COVID-19 pandemic [112]. These tools include a range of apps, text messaging interventions, web-based programs, wearables, and other digital technologies applied toward detecting, managing, or treating mental health conditions. Individuals with mental health conditions generally report openness to using these tools, reflecting factors like convenience, self-pacing, preference for self-reliance, and reduced stigma concerns and costs relative to face-to-face treatment [19,96,116].

Yet, despite success in reducing symptoms in clinical trials [32,41], most DMH tools have not achieved sustained use outside the research context, resulting in a so-called “research to practice gap” [57,68]. This gap in part reflects a less motivated user profile in the “real world” than is typical in trials, and the loss of resources and support outside the trial context. To address this, there is growing recognition that human support or “coaching” can play a key role in helping patients effectively use tools, apply learnings, and sustain motivation [5,65].

Deploying DMH tools within the healthcare system has been envisioned as a way to help patients make effective use of these tools, while also benefiting the care system through reducing demand for more intensive treatment resources, offering an ongoing view into the patient’s condition, and facilitating communication and data sharing between patients and care team members [12,26,99]. The concept of “technology-enabled services” was developed to reflect that a tool’s effectiveness and sustainability is not simply a function of the technology itself, but also how the tool is embedded within the routine “services” offered by healthcare workers [67]. Lewkowicz & Salembier [55] make a similar argument regarding the need for dual consideration of technologies and social practices. They propose that, to address critical societal challenges, multidisciplinary teams must come together to understand mediated cooperative practices and to design technological infrastructure (e.g., models, architectures, platforms) needed to support these practices. Thus, in the healthcare context, new activities for healthcare workers may also be required to make use of a technology, such as capture and review of patients’ data, attending to time-sensitive alerts, and communication and coordination around new data streams [77].

While integrating DMH tools in health services could improve quality and reach of mental health care, it also poses challenges, particularly when the work of supporting these tools falls to highly-trained mental health professionals who are already overburdened [3,99]. Fortunately, evidence indicates that coaching still has benefits for users when coaches lack professional mental health expertise [5,6,40,109]. Such findings have fueled optimism that DMH tools could be supported by care managers and care navigators [18,49,64]. This is consistent with coaching models such as the “supportive accountability” model, which suggest that a supporter or coach increases adherence to digital health interventions by creating a sense of accountability for the patient or end user that is built largely on the formation of a bond and the perception of legitimacy [65]. Here, the perception of legitimacy is based both on the coach having relevant expertise and on relational components - specifically, their trustworthiness and benevolence. Care managers may be well-positioned to provide a sense of supportive accountability, based on their expertise within the healthcare system and the strong relationships they are experienced at forming with patients, but their own needs as potential supporters of DMH tools are not well-understood.

2.3. Designing for Support Givers

Historically, work on DMH tools has focused on supporting an individual’s behavior change process or conceived of these tools as a component of formal treatment by specialists. This is beginning to change as researchers recognize that managing mental health is often a collaborative endeavor involving a range of individuals who play important and distinct roles (e.g., peers, friends, professionals) [14,51,70]. Yet relatively few tools have been designed to address day-to-day support-giving by health professionals who are not mental health specialists. While some studies have demonstrated that technicians who are not mental health specialists can effectively provide coaching for internet-based cognitive behavioral therapy (iCBT), these applied the same basic coaching protocol developed for mental health clinicians, apart from technicians being trained not to give clinical advice [98,113]. Thus, studies have considered effectiveness of non-specialist support for patients, but have not deeply engaged with non-specialists’ own experiences, ideas, and preferences around technology-mediated support-giving.

While not looking at care managers specifically, related studies in CSCW and HCI have examined how other support givers help patients manage their mental health concerns [52,53,123125], and how delivering technology-mediated support affects mental health volunteers [88]. Non-specialist health coaching has also been examined in relation to other health conditions [100]. Collectively, these studies highlight that support-giving involves significant labor and complex coordination, and has the potential to be draining or overwhelming both for informal caregivers (e.g., relatives who coordinate care for older adults with chronic and progressive health conditions [102]) and volunteers (e.g., those volunteering for suicide/crisis helplines [88]). These findings suggest that those providing support require adequate training, resources, and tools to meet their unique needs. For example, studies show that support givers may benefit from tools that allow for setting boundaries around contact to reduce the burden of always-on connectivity [86,87,91], for connecting with other support givers for mutual support and collaborative problem solving [90,123], and for relaxation and recuperation activities to counteract stress and burnout [88,111].

The public health community increasingly recognizes the importance of prioritizing healthcare workers’ needs and counteracting burnout. This is reflected in the proposed “quadruple aim” in healthcare, wherein the health system seeks to simultaneously achieve improvements in costs, patient experience, population health, and wellbeing and work life of the healthcare team [8]. When implementing digital tools, meeting this aim may include considering the training and guidance that accompany the introduction of a tool, how usable and useful the tool is within daily workflows, and how the tool shapes the experience of work to ultimately make it satisfying and sustainable. Deployments that fail to account for how those in the health system perform their day-to-day work can be disruptive and inefficient, leading to implementation failures [56,67]. Furthermore, since the views of stakeholders may not align as far as how they envision technology-delivered support, finding appropriate solutions requires working to carefully balance their needs [67,86,120].

In summary, attempts to scale support to address unmet mental health needs have involved increasing reliance on non-specialists and interest in use of technologies. Both approaches could potentially address gaps in the mental health system, but relatively limited work has explored the perspectives and needs of non-specialists themselves. Some recent work has sought to understand healthcare workers’ workflows and engage them in designing technologies, service plans, and implementation strategies [16,37,39,56,77,85,89], but has so far emphasized the work of mental health providers (e.g., psychiatrists, psychologists). Given the growing role of care managers as a point of contact and mental health support, it is important to understand how these workers believe DMH tools can be designed and implemented to better meet their own needs, and how their perspectives align (or do not) with those of their patients. We start to address these issues through our research questions in this study: 1) How do patients and their care managers conceive of care managers’ role in supporting mental health? 2) How do patients and their care managers envision that DMH tools could play a role within the care management process?

3. METHODS

3.1. Study Context

Data were collected in 2018/2019 as part of a larger ongoing research partnership with a Division of Care Management within a large health system in the midwestern USA. The care management program was designed to improve quality and cost-effectiveness through coordination of care for patients with complex health needs. Patients are referred to care management directly by their primary care provider or automatically identified through metrics in their medical records (e.g., high service utilization, non-compliance, poor control of chronic conditions). The care manager then collaborates with the patient’s primary care provider and helps the patient access specialized services in the wider healthcare system, as well as offering guidance in symptom self-management. The care management program had recently begun to integrate mental health support as part of care managers’ duties through standard assessment of patient depression using the Patient Health Questionnaire (PHQ-9) [46], and through hiring social workers with mental health experience to act as specialists within the team. All care managers were nurses and social workers by training. At the time of this data collection, the program employed 23 care managers who were spread across four sites representing urban and suburban settings in the metro area of a large Midwestern city.

To explore the issues around care management and delivery of mental health services, we conducted two related studies. First, we engaged care managers in a series of workshops to understand their perspectives on supporting patients’ mental health, their workflows around supporting patients’ mental health, and their views of the possible role of technologies in the support they provide. To understand patients’ perspectives on the same issues, we conducted semi-structured telephone interviews with 18 patients who had utilized the care management program, and had mental health needs as well as other chronic conditions.

3.2. Data Collection

3.2.1. Care manager workshops:

To understand care managers’ perspectives, we conducted a series of 10 workshops. Through their supervisors, the division’s 23 care managers were invited to participate in optional workshops - 17 participated. Two members of the research team facilitated a sequence of two workshops at each site, spaced approximately two weeks apart, with the same participants invited to both workshops. At the largest site, we held an additional sequence of two workshops to accommodate additional participants. Workshops ranged from two to five participants in size and lasted from 60 to 90 minutes. Care managers provided informed consent to record each meeting, including the brief introductions at the beginning of workshops to establish each attendee’s voice and role, facilitating later transcription. During the workshops, care managers answered open-ended questions about their views of mental health conditions, how they support patients in meeting mental and physical health needs, past experiences with digital mental health technologies, and their ideas and perspectives on adopting and using technologies as part of care management. The workshops also included two structured visual elicitation exercises wherein care managers drew or diagrammed 1) their process of supporting patients’ mental health, and 2) how they thought technology would best play a role in this process, after which each participant shared their reflections and ideas with the group. Participants were encouraged to engage with one another’s’ perspectives and ideas in group discussion. Our analyses here focus on care managers’ descriptions and discussion of their process and perspectives, rather than on the specific visual artefacts they produced. Workshops were audio recorded and transcribed by a professional transcriptionist.

3.2.2. Patient interviews:

To understand patients’ perspectives, members of the research team conducted semi-structured telephone interviews with 18 patients. Telephone interviews were selected to provide a familiar and convenient channel for patients to engage remotely. Eligible patients were recruited in two ways. First, care managers discussed the study with patients who had reported experiencing depression or anxiety in their conversations with care managers. Care managers obtained interested patients’ permission to pass their names and contact details to a research team member. Second, patients were sent a letter outlining details about the study and could contact the research team directly to express interest. Research team members contacted interested patients and administered a short screening questionnaire to determine eligibility. Individuals were eligible if they were 18 years old or older; were currently experiencing symptoms of depression or anxiety, as measured by a score of 10 or higher on the Patient Health Questionnaire (PHQ)-9 [46] and/or Generalized Anxiety Disorder (GAD)-7 [110] or reported experiencing depression or anxiety within the last 12 months; and were comfortable completing the interview in English. The screening survey also included a brief set of questions about demographics and current mental health treatment. While 19 participants started the study, one stopped the interview after 10 minutes due to fatigue, and their data were excluded from the analysis. Interview questions touched on mental health needs and how they are managed, experiences with care managers, the ideal role of care managers in supporting mental health, envisioned uses of DMH tools as supported by care managers, and anticipated barriers to use. Interviews were audio recorded and transcribed by a professional transcriptionist.

3.3. Data Analysis

For each dataset, data were analyzed following a thematic analysis approach [10]. Data from the workshops (with care managers) and phone interviews (with patients) were analyzed separately. The analysis of both studies was guided by the same two research questions: (1) how do care managers support mental health? (2) how could this support leverage DMH tools? Three coders were involved in coding the transcripts of the care manager workshops, and two coders in coding the patient interviews. The coders are authors of this paper. All had experience conducting qualitative research related to mental health services delivery.

In an inductive coding process, coders first read all transcripts to build familiarity with the data, independently performed open coding, and then met to discuss their initial codes, which were consolidated into a shared codebook. Refinement of the shared codebook then occurred iteratively through coders overlapping in coding a set of transcripts using the qualitative coding software DeDoose, then meeting to discuss areas of agreement and disagreement, and to resolve specific coding discrepancies. Codebook changes included refining code definitions, adding and merging codes, arranging codes hierarchically, and removing codes that were peripheral to the research questions. After coding meetings stopped yielding codebook revisions, the coders divided the remaining dataset between them and applied the final codebook.

3.4. Ethical Considerations

The research team included HCI and CSCW researchers and clinical psychologists, all of whom had prior experience working with individuals with mental health and chronic health conditions. Given the sensitive nature of the issues discussed in this study, our approach was developed in consultation with clinical psychologists on the team and was guided by consideration of the comfort and safety of participants. Participants were advised they could skip as many questions as they wished or end research activities early. Research staff had a risk management protocol in place in the event patients shared information signaling they were at risk to themselves or others. No such risks emerged in the study. Patients were compensated up to $50 for their time, depending on interview length. Care managers, who participated in the workshops as an optional activity during work hours, received $5 gift cards after each workshop as a small token of appreciation. All study activities were approved by the authors’ Institutional Review Board.

4. FINDINGS

The findings below describe, first, the themes we identified in the perspectives of care managers and patients on how care managers support their patients’ mental health. Second, we describe themes in care managers’ and patients’ ideas for designing and deploying DMH technologies to support care managers in this work. We label care managers CM1 through CM17 and patients P1 through P18. Information on care managers’ training and demographics are presented in aggregate to protect confidentiality.

4.1. How Care Managers Support Patient Mental Health

4.1.1. The care managers’ perspective.

In contrast to social workers and nurses who work through clinics providing care directly to patients, care managers’ role in this setting was largely remote, primarily coordinating and assisting patients in accessing care and resources and providing brief education around self-management as needed. That said, most care managers had trained and worked as care providers before. Most of the care managers had trained as nurses (N=13), while a few were trained as social workers (N=4). Five of the care managers had training in behavioral health and were considered behavioral health specialists within the care management program, including one of the nurses who had worked in mental health nursing for most of her career, and all the social workers, who had experience working as licensed clinical social workers and in inpatient, outpatient, and residential psychiatric settings. Care managers had been in their current roles for 2.4 years on average. Fifteen (88%) identified as female and 2 (12%) as male. Overall, they viewed their job as fast-paced and challenging but valued playing a direct role in helping patients gain self-efficacy and improve their ability to manage their health. One described their overall role as a process of helping patients develop skills that would serve them into the future: “Our goals for care coordination is to get them, link them to the things they need, [and] make them independent so they can self-manage” (CM10).

While mental health had not been emphasized in the formal training received by most care managers, they nonetheless relayed the importance of mental health care to patients. Furthermore, they reported high levels of mental health needs among their patients, including common issues like depression and anxiety. They reported that stress and disruption often occurred for patients in the context of managing multiple concurrent health challenges. One care manager described, “a lot of times they’re depressed because they’ve had a stroke, or they have [Multiple Sclerosis], or they have debilitating heart failure” (CM6). Others described mental health issues emerging or worsening in relation to other circumstances, like financial or housing insecurity, family caregiving duties, or grief.

Reflecting the recent initiatives in their division, care managers understood that they had been tasked with taking mental health into consideration as a regular part of their work. However, while there were some areas of consensus in how care managers should address mental health, there was also considerable variability among the care managers in how this was reflected in their daily work. Below, we highlight key themes we identified in our thematic analysis relating to how care managers viewed their work: 1) that assessment is important but ambiguous, 2) that expertise is needed to interpret and respond to mental health issues, 3) that the system often fails to provide timely access to mental health services, and 4) challenges in personally filling gaps in care.

The first theme was that assessment of mental health issues was a routine part of their work. After reviewing charts of patients newly added to their caseloads, care managers would typically perform assessments over the phone. Occasionally, they would meet face to face with patients, especially for complex cases or where they were having trouble understanding the patient’s situation. Care managers generally agreed that, in these initial interactions, listening, asking open-ended questions, and establishing trust provided avenues for a patient to share their concerns and allowed the care manager to develop a fuller picture of what the patient needed and to work with them on a plan to access resources. One described this as akin to solving a “puzzle”: “I feel like a lot of our cases are puzzles that the patient tells us what they need and facts about their case, and we have to give them the resources to solve their case” (CM12).

However, while commonplace, assessment was also an ambiguous process. Some described administering a formalized mental health assessment that included the Patient Health Questionnaire-9 (PHQ-9) for depression, as the division now required. Yet, care managers also voiced skepticism about the value of this assessment, and confusion about administration and interpretation. One care manager expressed concern that patients would not answer honestly: “Patients know how to manipulate that PHQ-9 and all of those psych tests that we do… so that they don’t have to have a conversation” (CM14). A few reported discomfort posing the questions. One asked, “I mean have you ever uttered the words, ‘Are you a danger to yourself or others?’ And felt ridiculous?” (CM16). Out of concern that discussion of mental health crises could be upsetting or awkward for patients, disrupt rapport, or damage trust, some would adjust question wording, or avoid the questions altogether, such as by using conversation to “glean bits and pieces” through which to complete the PHQ on the patient’s behalf (CM16). Many also reported a lack of clarity about how to understand or respond to patients’ scores. “We don’t really have any protocols,” described CM7, a statement endorsed by colleagues. They agreed that it would be helpful to have a better understanding of “If this, then this” (CM8), or a roadmap for what actions were appropriate given certain score ranges. In the absence of this, care managers reported a subjective and sometimes stressful process of weighing patients’ PHQ-9 scores alongside information available through chart review and conversations with patients.

The second theme identified was that mental health issues require help from others who had greater expertise. Indications of a challenge or crisis were a cue to escalate the case to a primary care clinician, therapist, psychiatrist, or the behavioral health specialists on the team. Care managers feared that if they missed an important cue, they might be responsible for a negative outcome, and given their limited confidence in assessing what was an actual crisis, reported being liberal in what they would escalate. For example, CM12 described, “If I have a little bit of a red flag, it goes to social work because I feel like they know this much better than I do.” Another described:

“When I look at the chart and I feel it’s heavy duty, I’m not going to touch it at all. It’s beyond my scope of practice, my skills. So that’s why I will just refer it to [the behavioral health specialist] … I really don’t have the know-how, the knowledge”

(CM6).

The third theme was that there were gaps in the availability of timely mental health services. For non-crisis mental health needs, care managers would regularly seek to connect the patient to mental health specialists, often helping to make an appointment, and sometimes following up to see if the patient successfully connected to the services. Yet while care managers emphasized their role in helping patients connect to care, the health system regularly could not provide the mental health care patients needed. They acknowledged frustration in this regard, since wait times for mental health appointments were often months long. One care manager described, “It’s really hard to call a patient and say… ‘There isn’t an appointment for six months, and I don’t really know – I can’t really do anything for you.’ It’s a really awkward position” (CM14).

The final theme was that care managers felt they could not personally cover these gaps in care. Beyond connecting the patient to immediate support in the case of a possible crisis, or working with the patient to access non-urgent mental health services, there was little consensus about what more care managers could do. CM9 emphasized that mental health issues were just one piece of the picture, and not her primary focus: “Understandably, that’s not my only goal while I’m on the case is for mental health issues. It’s usually medical. I tend to not be addressing that goal like my number one priority.” Indeed, for physical health issues, care managers had a good understanding, because of prior training or protocols, of how to support day-to-day self-management activities like diet and exercise, but they quickly felt out of their depth in relation to mental health self-management activities. Only a few reported supporting activities such as mood tracking, scheduling positive activities, or seeking social support in the community for mental health. A few care managers described providing empathic listening for patients on an ongoing basis. CM12 said, “There are also the few patients that really just want somebody to listen to them… I probably have a bunch of patients that really, I’m just kinda there for support.” For most, however, going into depth about managing mental health problems, or providing ongoing emotional support, was viewed as outside their role, the domain of providers with specialized training. CM11 described, “We are not on the front line; we are just aligning patients with resources.”

Care managers often pointed to the limited time they had with patients, which undermined their ability to provide ongoing support. One explained, “We’re talking to these patients maybe once a month if we can get them.... And our job is to be so temporary in their lives… A lot of the time, for me anyway, is spent building boundaries” (CM8). Empathic listening was challenging in this regard because it blurred boundaries around appropriate contact. CM15 described that providing empathic listening had created situations where the level of contact from a patient had become overwhelming, recalling, “All of a sudden, I’ve got where I’m talking to them every other day for about a month… I’m sitting there going, ‘Do you really realize I’ve got 86 patients on my panel and I don’t have the 25 minutes?’” Receiving mental health disclosures was also viewed as draining, sometimes activating negative personal associations and emotions, as another described:

“Sometimes I struggle with things that the people are sayin’ to me because they hit me in a certain place, personally. You know? And I’m thinkin’, ‘Okay, let me distance myself and be – try to be more objective.’”

(CM17)

Similarly, CM16 shared of working with patients with anxiety, “I can feel my heart, you know, just beating faster just talking to them.” Thus, many care managers had experienced or feared intrusions or discomfort from caring for mental health outside their expertise and training, especially in the context of their busy roles.

Those care managers with behavioral health training were understood by their team members as being able to better understand mental health issues, including supporting mental health assessment, and navigating the landscape of mental health services and resources. However, regardless of training, they faced similar challenges in supporting patient mental health, such as large caseloads that impeded their ability to build ongoing relationships. For example, one of the social workers explained, “It’s not our role to have patients for six months or longer, because we really have to help so many people” (CM12). Thus, care managers distinguished their role from that of mental health providers who deliver ongoing care.

Overall, care managers reported increasing focus on mental health assessment, but that their work did not generally encompass providing ongoing support for mental health self-management. Despite lamenting the gaps in access to timely care, care managers themselves felt unprepared or too busy to respond to many mental health challenges, and some felt discomfort at discussing patients’ mental health. As the next section describes, these role conceptions and limitations were not well-understood by patients, who had a different understanding of how care managers worked and how they could help.

4.1.2. The patients’ perspective.

Eleven participants were female, 6 male, and one non-binary. Fourteen participants self-identified as White, three as African American, and one declined to respond. They had generally dealt with mental health symptoms for many years, alongside an array of medical conditions. These included diabetes, multiple sclerosis, arthritis, traumatic brain injury, and autoimmune diseases, among others. In addition to depression and anxiety, they disclosed other mental health issues such as post-traumatic stress disorder, bipolar disorder, and obsessive-compulsive disorder. Additional participant characteristics are in Table 1.

Table 1.

Demographic Characteristics and Health Status of Patients

Study ID Age Gender Depression symptom severitya Anxiety symptom severityb Current mental health treatment
P1 63 Female Moderate Moderate
P2 39 Female Mild Minimal Medication
P3 67 Male Moderate Mild
P4 40 Female Moderately severe Moderate Medication and psychotherapy
P5 44 Male Moderate Mild Medication and psychotherapy
P6 88 Female Minimal Moderate
P7 39 Male Minimal Moderate Medication
P8 83 Female Moderate Mild Medication
P9 49 Female Minimal Minimal Medication and psychotherapy
P10 49 Female Mild Mild Medication and psychotherapy
P11 55 Female Moderate Severe
P12 67 Male Moderately severe Moderate Medication
P13 65 Male Minimal Mild Medication and psychotherapy
P14 65 Female Minimal Minimal Medication and psychotherapy
P15 59 Male Minimal Minimal
P16 88 Female Mild Minimal
P17 58 Female Minimal Minimal
P18 33 Nonbinary Minimal Minimal
a

Based on the PHQ-9 [46], scores of 0–4 are minimal, 5–9 are mild, 10–14 are moderate, 15–19 are moderately severe, and ≥ 20 are severe

b

Based on the GAD-7 [110], scores of 0–4 are minimal, 5–9 are mild, 10–14 are moderate, and ≥15 are severe

Like care managers, patients saw the importance of addressing mental health concerns, and saw mutual influence between physical health challenges and symptoms of depression and anxiety. One patient described, “I have two auto-immune diseases… They impact my life pretty dramatically and they also increase the chances of depression” (P1). However, while they could be exacerbated by physical health conditions or other circumstances, many patients emphasized that their mental health concerns were long-term issues, not strictly situational or temporary. Furthermore, whether or not these issues rose to the level of a crisis, and whether individuals were receiving formal mental health care at a point in time, patients felt these concerns still called for proactive, ongoing self-management. Most patients described that, over time, they had assembled a set of strategies to help keep their symptoms in check or prevent recurrence, including physical activity, social support, checklists and reminders, meditation, thought restructuring exercises, and app use.

As far as care managers’ involvement in addressing their mental health needs, a few recalled helpful interactions. One patient described that her care manager took steps to make her feel cared for:

“[The care manager] would talk to you a little bit more. ‘How's this going? How that’s going?’ I liked the personal touch, and again, she remembered, she knew who I was. I guess we all like extra attention. At least, I do, from time to time”

(P14).

Other patients were largely unaware of the efforts care managers were making. Although they had all been in contact with care management recently per the study inclusion criteria, some could not recall interacting with a care manager at length or discussing mental health. One patient described that her contact with the care manager was very brief: “It must’ve not been a lot [of contact] because I don’t have a firm memory of that person” (P10). This may reflect care managers’ limited time with patients and ill-defined role in mental health support, as described in the prior section.

That said, the idea of care managers acting as a resource to help patients meet their mental health needs was endorsed by almost all patients. Our analysis identified several themes in the desired role of care managers, including 1) complementarity of care manager support and other services, 2) desire for non-judgmental support, and 3) desire for consistency.

In line with the theme of complementarity, the care manager’s role was not seen as replacing that of mental health specialists, but as a source of ongoing supplemental support. For example, patients thought that care managers could help them sustain motivation needed to connect to specialist providers or follow-through with providers’ recommendations. One patient described how the care manager might have helped when seeing a psychiatrist:

“I got the referral and then I got the prescription, but I was very hesitant to do it and I think maybe having the care manager would have pushed me or motivated me to do so and help me see through the nonsense – not nonsense, see through the fog of being depressed, to actually take the step in the right direction or be my advocate”

(P1).

Other patients emphasized that care managers’ guidance and encouragement might help them to perform an array of day-to-day self-management activities outside therapy sessions. For example, P11 described the care manager might help by “giving me tools to cope. How to cope with this situation of choosing to talk out your emotions instead of eating your emotions.” Thus, patients generally recognized a helpful role for care managers that they differentiated from a provider’s role.

The second theme was patients’ desire for non-judgment from care managers. When asked about the personal qualities and type of relationship they would want in a care manager who supports their mental health, they overwhelmingly described nonjudgmental listening and understanding. One described, “I would just like to be honest and just say what’s really bothering me without being judged” (P4). Similarly, P11 envisioned an ideal relationship with a care manager: “There’s that encouragement, and that care and concern.”

The third theme was that the ideal support from a non-specialist was characterized by consistency. One described,

“it’s going to take some time to create that relationship with that person, where then, they’ll be able to be helpful… I would think that they would probably be more and more helpful over the course of time”

(P17).

As the above findings suggest, care managers understood their role as assessing patients to link them to more skilled or experienced mental health care, but patients envisioned a regular role for care managers that did not require mental health expertise and that could sustain their motivation and keep their self-management on track, consistent with the supportive accountability model of non-specialist mental health support [65]. Furthermore, the envisioned collaborative role also mirrors the role care managers often play in supporting patients to manage physical health concerns. As the next section explores, each party’s understanding of the care manager’s role provides the backdrop for their ideas about the introduction of DMH tools.

4.2. How DMH Tools Might Help

Below we describe how DMH tools could play a role in management of patients’ mental health concerns, as perceived both by care managers and patients.

4.2.1. The care managers’ perspective.

We identified three key themes in how care managers thought about the integration of DMH tools: 1) enthusiasm for deploying tools as a stopgap when mental health services were not available, 2) interest in improving their own information systems and assessment tools, 3) concerns about providing ongoing support of DMH tool use or adopting technology-mediated communication with patients.

In line with the first theme, care managers embraced the idea that patients might use DMH tools independently to help bridge gaps in care. Some care managers had heard of or tried popular meditation, well-being, and therapy apps, and appreciated the convenience and the relative low costs of these tools. A few reported recommending tools like smartphone-based meditation apps to patients, or providing encouragement when patients mentioned use of these tools. Others who had less experience with DMH tools expressed that they would be interested in recommending such tools to their patients if the tools had been approved or endorsed by the healthcare organization and were evidence-based. DMH tools were viewed as a potential stopgap that could help patients in the stretches of time they might need to wait before accessing mental health services, as one described: “It takes the wait out of having to wait how many months” (CM4). She went on to describe the always-on nature of digital support, beyond the hours of formal health services: “Maybe they’re awake at 2:00 in the morning and anxious, not suicidal. But they need someone to talk to, even if it’s just a phone call or an app.” However, the idea of referring DMH tools to patients did raise equity issues, with older adults and those with lower incomes being seen as having less access to technologies.

In line with the second theme, care managers also envisioned ways that digital tools could be designed for their own use, such as when conducting assessments or locating resources. Several care managers described that they would like the ability to input a patient’s symptoms or other case information into a system and receive tailored recommendations of evidence-based tools and strategies, community resources, or psychoeducation materials. Some also envisioned receiving real-time feedback on how to respond to patients’ scores on formal assessments like the PHQ. Given care managers’ discomfort in administering these assessments, and patients’ presumed discomfort in responding, a few suggested fully automated assessment, such as could occur through a smartphone app. CM3 envisioned,

“They put [their response] in every day or they put [it] in weekly, just to see where they’re at. And then, based on the answer, [it] triggers more questions… If “severe” triggers, it sends an alert maybe to the primary care doctor and the social worker saying, ‘Hey, this patient is having this feeling right now’ – an immediate alert. And then based on questions, provides suggestions, materials – kinda like… behavioral therapy type of exercises.”

In this example, technology-based assessment was viewed as a means to gather ongoing data and provide just-in-time support for the patient, while limiting care managers’ direct involvement.

In regard to the third theme, care managers discussed limited involvement in collaborating with their patients around DMH tool use beyond the point of assessment. Generally, they reported willingness to help refer and orient the user to a DMH tool, as one described: “I think, based off your assessment, you… implement and explain the app. Walk the patient through, if needed, how to use the app. You could go over it over the phone” (CM3). However, care managers did not envision offering training or extended education about tools, using tools together during meetings, accessing data from tool use, or checking in about tool use. Some perceived that such ideas were “not realistic” (CM5), as these activities would exceed care managers’ current availability and expertise. CM11 described, “it’s really gonna be the patients using it… That’s my takeaway for you guys, is we are not getting into the deep mire with these people. That’s not our role. That’s not our job.” Some suggested that review of patients’ uses and experiences and an app might be the domain of clinicians, suggesting, “It’s probably more fruitful in those arenas, where you can check in with your therapist once a week or every other week to see what your mood journal was for the last ten days, or something like that” (CM13).

Care managers also described concern about communicating with patients directly through digital channels (beyond telephone calls). While noting the convenience of text messaging or other text-based and asynchronous forms of communication, care managers expressed concern that these channels would not allow for building rapport or truly understanding patients’ needs. One care manager spoke to the importance of cues available on telephone calls, such as “tone, pitch, frequency of speaking, … loudness” (CM1). They were also concerned about displacing in-person meetings, which provided rich information about appearance, hygiene, body language, demeanor, and environment. These cues were viewed as essential especially when something doesn’t “add up” about the case (CM3). There was also concern that DMH tools could break down boundaries around appropriate contact, giving patients the ability to reach care managers at “all kinds of odd hours,” disrupting and adding stress to their already chaotic days (CM4). Finally, several relayed concerns related to privacy and liability around text-based communication or mentioned that texting was against the current policies of the organization, and noted the slow pace of change for such policies.

Thus, while care managers were interested in providing DMH tools to patients and in using systems to help with assessing patients and connecting them to tailored resources, their vision for collaborative management of mental health via technologies was limited. Furthermore, they had concerns that new communication channels could replace or disrupt the rapport, information-gathering, and boundary-setting that were central to their work. This limited vision of collaboration can be contrasted with patients’ views described in the next section.

4.2.2. The patients’ perspective.

Like care managers, patients generally had familiarity with smartphone-based DMH tools available to consumers. Many had used these, as well as having experimented with a variety of digital tools not specifically designed for mental health, but which they found useful, such as streaming services and digital to-do lists. We identified two themes in patients’ envisioned uses of such tools. First, whereas care managers largely envisioned patients using DMH tools independently, patients often described collaborative roles that care managers could play in supporting their use of these tools. Second, they wanted to select between multiple possible modes of communication with care managers to match their needs in a given moment.

In line with the first theme, patients’ envisioned interactions with care managers around DMH tools generally went beyond initial referral, set-up, and training. Frequent ideas included care managers’ reviewing patients’ app use data and conversing with them about their technology-supported behavior change process. One described that the level of contact would likely shift based on patients’ needs: “I would think at a minimum once a week because you want to set some goals and you want to track them.” (P15). P11 described that, regardless of the specific schedule, regular contact provides important structure: “That helps me stay on track. It helps me stay focused, and it helps me to stay engaged.” P17 elaborated on how a tool might capture information about the specific skills the patient was learning and challenges they faced, which could facilitate tailored support wherein care managers

“might be able to use that more specific information about the skills or maybe about, like you say, sleep or social activities… to guide you in a direction that is going to be beneficial. ‘Well, I noticed you haven’t slept that well lately.’ Maybe they could investigate certain aspects of what’s going on, to try to see how that might be affecting it overall.”

One important caveat, though, was that such sharing builds on an ongoing relationship:

“Some kind of relationship has to be built beforehand. But once you’ve built that, maybe a few conversations and that type of thing, and then the care manager maybe suggests that it would be helpful for them to be able to help me to be able to see more information”

(P17).

In line with the second theme, patients overwhelmingly supported having multiple options of communication channels through which to contact care managers (phone call, video-chat, in-app messages, text, email). They envisioned that each channel might have its own place in their interaction, depending on their shifting needs and preferences. For example, one described that text-based communication would generally be preferred “because a lot of times, phone calls, you can’t answer if you’re at work or if you don’t feel like talking. You might not get the opportunity to fully share what is going on because of privacy reasons” (P1). Similarly, P18 shared that “I would prefer for [the method of contact] to be something like via email, where I can choose when, how, and what I’m going to say back to them,” although they also noted that, if the issue were time-sensitive, a phone call could sometimes be more efficient. Thus, despite care managers’ perceptions that the reduced cues in text-based communication would compromise building rapport, most patients indicated willingness to disclose and build relationships with care managers through text-based and asynchronous channels, or indicated a preference for such channels. They saw little reason to interact with care managers in person, in contrast.

Overall, like their care managers, patients expressed interest in using DMH tools to improve their mental health. However, unlike care managers, patients envisioned that once trust and rapport had been built, they might collaborate with care managers in using DMH tools, with their data providing insights and information for care managers to tailor the support they provided. Patients also described willingness and perceived ability to communicate meaningfully with care managers via a large range of channels without threat to rapport or disclosure.

5. DISCUSSION

If they can be successfully integrated in the healthcare system, DMH tools have been proposed as a way to help address a massive treatment gap for common mental health conditions. As part of a transition toward “integrated” and “coordinated” care, care managers are increasingly tasked with helping patients with complex needs navigate US healthcare systems. It has been proposed that these care managers could provide the support that patients need to benefit from DMH tools while also improving quality and efficiency of care [49], which is consistent with a broader trend of involving non-specialists in mental health support [18,24,50,64]. However, there remains the need to define how DMH tools would fit within care managers’ daily work. Our findings suggest that care managers face considerable stress, which reflects their position as a fulcrum between the patient and the health system. While the health system cannot reliably provide access to timely mental health care, care managers themselves feel overextended and unprepared to provide ongoing support for mental health issues. Their vision of a temporary role in patient’s care, and of limited collaboration, is in tension with that of patients, with patients describing they would welcome ongoing support from and communication with care managers. In our discussion, we situate these findings in literature on technology-mediated support in health care, emphasizing how intense demands on healthcare workers’ time and energy lead them to approach relationship building differently than do their patients. Specifically, while both groups discussed the value of rapport, care managers were constrained in building ongoing or close relationships by the volume of their caseloads and by discomfort discussing patients’ emotions. They also feared that new technologies might disrupt boundaries they have built around patient contact and emotional labor. For patients, we discuss the importance of a supportive relationship in which trust develops over a longer timeframe. We then lay out ideas for how design and implementation of DMH tools can be responsive to the distinct needs of care managers and their patients, and discuss the need to consider the structural challenges care managers face, which cannot be resolved through a technology alone.

5.1. Shifting Expectations of Care Managers’ Work

In our findings, we described that care managers face substantial pressure because of the role they play within the health system. Care managers emphasized that their role, in theory, involves serving as a conduit to appropriate care within the system. In practice, however, they are often unable to fulfill this role because of the limited availability of mental health services. Despite recognizing the gaps in care within the system, care managers did not envision that, given their considerable responsibilities and lack of training, they could provide traditional “coaching” of DMH tools, such as reminding and encouraging use of the tool, reinforcing skills learned through a tool, or reviewing patients’ data. They also had concerns about communicating through text-based channels, why is often part of coaching.

A number of studies have observed, consistent with our findings, that healthcare workers tend to be more wary about integrating digital tools than their patients [58,86,89]. This pattern relates, in part, to healthcare workers’ past experiences of implementation of new technologies (e.g., electronic medical records). While these technologies were designed to serve important functions, workers’ own needs, workflows, and collaborative practices have not routinely been prioritized in their design and implementation [47], leading to inefficiencies such as parallel uses of new and old systems [33], work-arounds [71], and “articulation work” wherein, beyond their specified duties, workers must engage in meta-coordination to define how a team can successfully collaborate to carry out new tasks or use new tools [1,9,82]. Health care workers may also be skeptical when digital tools are viewed as a cost-saving measure, such that they are deployed to reduce the level of services available.

Yet, beyond simply fearing that technologies might increase the demands placed on them, care managers also expressed concerns around the specific types of labor that would be involved in supporting DMH tools. Therefore, our findings also point toward a fundamental tension emerging between patients and care managers around the general nature of care managers’ work in mental health support. Beyond assessing patients and linking them to services, care managers had limited understanding of what they could do to help patients manage mental health issues. Many also relayed that engaging patients around mental health issues felt uncomfortable, draining, and stressful, as has also been described in other settings where workers give mental health support without sufficient training and resources [88,94,111]. To understand this dynamic, it is important to recognize mental health support-giving as a form of emotional labor. First described by sociologist Arlie Hochschild in the 1980s [36], this term describes paid work, in a public-facing role, wherein the worker is responsible for managing the emotions of others. Such labor can be time-consuming and challenging, as those performing it must carefully modulate their own emotional expression in order to produce the desired feelings in the client, customer, or patient [27,48,92]. For example, our findings described that care managers who provided empathic listening to patients felt exhausted by the need to temper their own emotional responses and maintain composure. Given their limited time and large caseloads, giving this type of support was not only draining, but could also be counterproductive, leading to falling behind in helping other patients. To meet the demands of their job, care managers described strategies such as referring mental health issues to those with more training and drawing boundaries around appropriate patient contact. Providing coaching for DMH tools was viewed as disrupting these self-protective strategies, potentially making care managers available to patients at any time and leading to expectations that their role entailed ongoing care and emotional support.

In contrast, patients had enthusiastic views about receiving mental health support from care managers, including support of DMH tool use, and support delivered through digital channels. Rather than emphasizing how care managers might help them through referral and assessment, patients overwhelmingly described benefits that accrue directly from interacting with supportive care managers, including feeling cared for and motivated. On the whole, patients’ views of the ideal role for care managers are largely consistent with the “supportive accountability” model, where a coach provides direct, personalized support for patients as they use new tools, and where this accountability can be strengthened by the development of a bond and by relational factors like trustworthiness and benevolence [65]. Past work likewise suggests that, regardless of formal mental health training, compassionate others can sustain motivation to carry out an array of self-management strategies, and to engage productively with DMH tools over a time-frame sufficient to benefit from them [5,6,25]. Patients may lack visibility into the constraints healthcare workers face in terms of on-demand availability [87], which likely shaped their optimistic views of an ongoing supportive relationship with regular contact. Thus, whereas care managers understood their role in mental health support as limited and temporary, patients envisioned a relationship that would unfold over months and that would involve direct provision of emotional support. These fundamental tensions provide the backdrop for introduction of DMH tools.

5.2. Design Considerations for Technology-Enabled Mental Health Services

To be sustained in the healthcare system, technologies must meet the needs of both patients who use them and healthcare workers who implement them. In this section, we explore considerations for designing and implementing technologies to balance the needs of patients and their care managers. We highlight a few areas where care managers and patients agree there are needs that could be addressed by technologies (e.g., directories of DMH tools). We also discuss ways systems could be designed to make support-giving less effortful for care managers, supporting both assessment and rapport. Finally, we highlight the risks if care managers are asked to fill fundamental gaps in mental health care; as we integrate mental health into the broader care process, we need to not only consider the design of technologies themselves, but also the design of the services, processes, and policies that undergird technology use. Thus, care managers’ training and responsibilities would likely need to fundamentally shift before they take on an ongoing role in supporting DMH tools.

It should be noted that, despite care managers’ concerns about supporting DMH tool use, there were two areas of need that they felt could be met through technologies. First, care managers described feeling uncomfortable with mental health assessments or mis-administering them (e.g., filling in the PHQ-9 on the patient’s behalf instead of directly asking questions). Past work in HCI has examined systems to support delivering mental health screenings and linking patients to tailored resources in medical contexts [60,120]. For example, Web et al. [120] proposed a tool enabling patients to complete mental health assessments on their own devices and in their own time, and to elaborate and provide context through free-text responses, while providing this information is summary form to providers. Similar systems may be helpful in the care management context. Furthermore, our findings suggest that systems that deliver assessment results to care managers should provide support for interpretation of scores (e.g., mild versus moderate symptom levels), and suggest tailored resources and psychoeducation materials that care managers can provide to patients. Second, care managers lamented the long-wait times patients faced when seeking specialty mental health services, noting that these waits caused distress and dropout for patients, and were demoralizing for care managers. Therefore, care managers largely embraced the idea of patient-facing DMH tools that could fill in gaps when services are not available, including apps that provide on-demand support. Reflecting the rapid proliferation of DMH tools of variable quality and relevance, some past work has sought to develop and implement resources and best practices for finding tools that match an individual’s mental health needs, such as directories of evidence-based DMH tools that can be filtered based on symptoms or an individual’s preferences [75,115]. Making such resources available to those waiting for services could potentially help both patients and care managers, particularly if tools are validated and effective and endorsed by the organization.

On the other hand, a large body of evidence shows that ongoing human support is key to many users’ sustaining use of DMH tools and benefiting from them [3,5,115]. Care managers’ and patients’ viewpoints diverged strikingly around the issue of ongoing support for patients’ tool use. Given care managers’ concern that they should operate within their expertise and not be responsible for mental health crises, tools that prioritize care managers’ needs should likely be delivered alongside clear protocols for managing risk, and an option to escalate issues to behavioral health specialists on the team, or to receive supervision and training around delivering mental health support. Such options might relieve stress associated with feeling responsible for emergency situations, and would facilitate building support-giving skills, potentially creating a supportive culture that can counteract burnout [27,50]. Collaborative tools used by care managers must also be designed to recognize care managers’ limited time and heavy caseloads, and to address their stress and unease when discussing mental health. One model of coaching that may be helpful here is the “efficiency model” [103], wherein support-giving is distinguished from therapy, prioritized for patients with the greatest need, and delivered only when the cost/benefit ratio is favorable. This may be supported by dashboards that sort and label patients by level of need based on assessments and other information from health records. Systems may also provide mechanisms for setting expectations with patients about when care managers are available and when a reply is expected (e.g., clarifying a tool is not intended for seeking urgent support and that responses are typically provided within 24 hours, or alerting patients when they are messaging care managers outside their availability) [50,125].

Care managers’ and patients’ needs should also be balanced when considering communication channels. Patients wanted the option to use lower-bandwidth (e.g., text-based) communication channels. This finding is in line with the “hyperpersonal model” of computer-mediated communication, which posits that text-based, asynchronous media allow for more careful and less rushed message composition, such that individuals can present themselves in deliberate ways, leading partners to form idealized perceptions of one another [44,118]. This model has been integrated into the supportive accountability model of coaching [50,65], with low bandwidth channels being proposed as a good fit for building relationships between patients and coaches. On the other hand, our findings also suggest that bandwidth operates differently for busy care managers. Specifically, higher-bandwidth media (e.g., synchronous phone calls) were perceived as critical in assessment, a finding which is consistent with studies showing the need for more cues in ambiguous or time-limited communication contexts [21,80]. To balance these needs, DMH tools used by patients and care managers might allow for shifting between channels based on preferences and needs of both members of the dyad. For example, synchronous voice or video calls could be the default during an initial assessment, but in subsequent interactions, various options might be offered so patients may select communication channels that make them more comfortable.

An important final consideration is that connecting patients to timely mental health support may require adjustments to the nature of the work or to the workforce [35,67]. Regardless of the tools available to them, many care managers were fundamentally uneasy with supporting mental health. They also felt at risk of being overburdened by playing a greater role in mental health. In collaborative care, if the work of mental health support falls unevenly on care team members, this could contribute to burnout and may represent a threat to these care models [84]. In their current role conception, care managers serve largely as a conduit to providers who are better equipped to provide care, and to fulfill this role requires formal mental health services being readily available to patients. This likely requires solutions at the systems level, such as strengthening mental health treatment in primary care, increasing mental health competencies in the health workforce, adequate incentives and reimbursement for mental health care, and improving access such as through transitions to telehealth [23,29,42,45,112]. As integrated care is supported by new technologies, solutions may also involve new roles, such as “digital navigators” who support patients in selecting and effectively using digital tools [122].

If care managers are asked to take on a greater role in mental health support themselves, our findings suggest that broad reconceptualization and reorganization of the care managers’ work would be needed, as well as additional training. Care managers identified that they had important gaps in their understanding of mental health. Training might address some key gaps by clarifying how common and chronic mental health conditions are, their typical symptoms, and protocols for dealing with potential risks and crisis situations. Training could also convey that these conditions require ongoing management by the patient, analogous to physical health conditions, and may introduce common self-management strategies that patients find helpful outside of treatment, like physical activity, mood tracking, social support seeking, behavioral activation, and thought restructuring, among others [13,97]. It is also essential to consider ways to make more time available within care managers’ work for mental health support. For example, making time to regularly follow-up with patients regarding their mental health may be more feasible when care managers have smaller caseloads (e.g., by expanding the care manager workforce), when other activities can be offboarded (e.g., if mental health assessments were automated versus being conducted by care managers), and when adequate supervision is provided (e.g., through more collaboration with behavioral health specialists). Thus, re-envisioning care management is likely a necessary precursor to extending care managers’ work to encompass ongoing coaching of DMH tools, and would require buy-in and participation from an array of stakeholders including administrators, managers, technology designers, and care managers themselves.

5.3. Limitations

This study has limitations. While we attempted to reduce the burden of participation on both care managers and patients (e.g., by traveling to care managers’ work sites, and by engaging patients remotely), those who participated in this research may not perfectly represent the population of end-users. For instance, patients were eligible based on current or previous depression or anxiety symptoms, but some patients served by care management have other mental health conditions. In addition, those who chose to participate may have been relatively enthusiastic about DMH tools, and more willing to discuss mental health. It is important that DMH tools also appeal to and meet the needs of those who are less motivated or comfortable disclosing their concerns, and therefore future work should further reduce barriers to participation where possible. While most care managers within the care management program chose to participate in this research, and while they seemed to share candidly about their perspectives, we should also note that care managers were recruited through their employer, which could introduce social desirability concerns. We attempted to mitigate potential bias by noting that their feedback would be anonymized, and that recordings and transcripts would not be shared with managers. An additional consideration is that the samples involved are drawn from a particular US healthcare system and care management program. Such programs are diverse in terms of care managers’ specific duties, training, and patient populations served. Future work might seek to better understand how care managers envision the application of DMH tools in programs where care managers have more specialized mental health training or smaller caseloads. Finally, these data were collected prior to the COVID-19 pandemic. In future work, it may be useful to understand how care managers and their patients have shifted their views and practices since the pandemic. For example, the pandemic shifted availability of telemedicine and uptake of DMH tools and may also have resulted in a greater mental health burden and need for support.

6. CONCLUSIONS

As most individuals in the US who have mental health conditions are not connected with specialty mental health care, it is critically important to understand how DMH tools may be deployed in medical care more broadly, and as a part of integrated care. In this study, we highlighted how care managers and their patients envisioned different applications of technology, reflecting disparate conceptions of the care manager’s role and relationship with the patient. While there was some interest and enthusiasm from care managers about how technology could help, they envisioned providing limiting ongoing support for patients’ DMH tool use. On the other hand, patients - who had limited understanding of the care managers’ current role - envisioned connecting with their care managers through technology as needed, with ongoing supportive contact playing a key role in their mental health care. While there are opportunities for application of technology to help solve needs that care managers and patients agree on, further work is needed to reconcile patients’ and care managers’ views of what constitutes appropriate mental health support from a care manager.

CCS Concepts:

  • Human-centered computing ~Human computer interaction (HCI) ~Empirical studies in HCI

ACKNOWLEDGMENTS

We are grateful to the individuals who participated in this research, as well as to Ada Ng, Susan Kaiser, Shefali Halder, Jonah Meyerhoff, Andrea Graham, and Kate Ringland for support in collecting data and providing feedback on data analysis. This work is supported by the National Institute of Mental Health under grants P50MH119029, K01MH125172, and T32MH115882, and by the Agency for Healthcare Research and Quality under grant R01HS028003. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Contributor Information

RACHEL KORNFIELD, Northwestern University, USA.

EMILY G. LATTIE, Northwestern University, USA

JENNIFER NICHOLAS, University of Melbourne & Orygen, Australia.

ASHLEY A. KNAPP, Northwestern University, USA

DAVID C. MOHR, Northwestern University, USA

MADHU REDDY, University of California, Irvine, USA.

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