Table 1.

Problem-solving Challenges to Implementing Mental Health Collaborative Care in Routine Primary Care Settings. Data from Unutzer and Park [7], Thielke and Vannoy [12], O'Donnell et al [15], O'Donnell et al [22], Whitebird et al [47], Lauren Crain [48], Taylor et al [55], and Kathol et al [99].

CCM Component	Implementation Step	Challenges	Solutions
	Adopt EMR/electronic registries	• High costs to adopt, build, and maintain • Mental health notes separate from medical EMR • Barriers to population registries	• Seek CMS/HITECH EMR funding • Negotiate EMR costs into bundled payments • Establish payment for measurement-based care • Develop networked “neighborhood” registries
Clinical Information System	Adopt standardized outcome measures	• Diverse measures and measurement protocols for screening/follow-up	• Achieving consensus on key mental health and physical tracking measures (embed in EMR) • Standardize frequency of follow-up contacts
	Negotiate performance measures	• Unknown costs for new workflows • Business model not established	• Work with practice networks, health agencies, health plans, insurance exchanges to identify common measures to evaluate patient progress, align incentives
	Adopt care management/team care	• Lack of staff/provider buy-in • Physician centric culture	• Physician champion aligns realignment with values • External facilitation to support transition
Delivery System Redesign	Develop standardized protocols for diagnosis, follow-up measures, stepped-care, referrals Specify care management protocols	• Cost of training and changing workflow • Poor coordination between team • Role ambiguity, provider competing demands • Provider competing demands	• Establish blended payments to general and specific care coordination procedures • Specify work roles and methods to communicate patient information, referrals, urgent consultations • Physical colocation of medical and mental health staff
	Identify MH diagnoses for treatment and who delivers specific treatments	• Supply of interdisciplinary behavioral health staff • Multiple patient comorbidities	• Negotiate reimbursement and competencies for specified professionals (licensure, credentials, training, skills) • States incentivize interdisciplinary training programs • Negotiate patient goals and treat to “target”
	Engage patients in care	• Practice is patient flow vs. patient-centered	• Measure satisfaction, emphasis feedback, and indicators of shared decision-making in EMR/registries
Self-Management Support	Identify brief evidence-based treatments	• Reimbursement for training/supervision • Practice treatment capacity	• Negotiations for bundled payments for self-management • Establish protocol length, visits, & stepped-care protocol
	Implement health promotion counseling and who to deliver	• Focus on single MH or disease condition • Lack of reimbursement for wellness	• Have cross-disease focus • Available to all patients • Negotiate reimbursement, performance measures
	Referrals to community/specialty care	• Patient and provider stigma • Poor referral uptake by patients • Lack of follow-up	• Train staff to de-stigmatize MH conditions • Offer onsite or e-health mediated treated when possible • Establish follow-up procedures for community referrals
	Establish space/delivery mode	• Inadequate space/staff	• Contract self-management to phone/e-health provider
	Train staff/physicians in guidelines and measurement based care	• Stigma/negative attitude towards MH • Lack of training in MH diagnose/care	• Allocate funds for staff/provider training • Train in diagnosis and screening • Create simplified guideline supports for stepped-care medication, psychosocial, and referral strategies
Provider Decision Support	Establish mental health specialist services	• Undefined role and reimbursement	• Specify contractual obligations for MH panel and care manager supervision, consultations, facilitating referrals • Decide if colocated or offsite
	Define care manager functions	• Capitated payments do not cover care management	• Reimbursement based on care management functions of diagnosis, tracking, medication support, brief psycho-education counseling, prompting physicians for treatment changes, relapse prevention, registry updates
Community Linkages	Creating network of community resources (specialty mental health transportation, housing, wellness, , employment)	• ACO serving wide geographic regions or dense urban settings lack sufficient community connections • Poor patient uptake of specialty mental health referrals	•Local practices create network or health “neighborhood” directories of local resources and providers • Develop links with local specialty mental health resources/providers for warm hand-offs
	Ensure leadership buy-in and support	•Integration from health plan vs. practice • Poor relationship between leaders and frontline providers and staff	•Align CCM restructuring with practice values • Consult with practice facilitator
Build Leadership and Organizational Support	Establish priority for system redesign with CCM components	•Lack of priority for measurement based care • Inertia to redesign workflows, procedures, and billing processes	• Identify physician and mental health champions
	Create a sustainable business model	•Lack of financial business model • Financial costs for investing in CCM components and maintenance • Unbillable activities for new provider types, services, and processes of care for • Lack of stakeholder input	•Achieve consensus on the value of CCM with regional and state healthcare stakeholders, key tracking outcomes • Assess the types of providers, location/size of practices, and the intervention components to deliver • Measure new costs to understand new financial model • Establish working group of stakeholders (e.g., providers, plans, employers, patients) to define performance outcomes • Propose and negotiate a reimbursement model involving neutral 3rd party to move from fee-for-service to bundled payments model that covers costs of CCM redesign