Success Stories in Collaborative Care

Below are brief stories that convey in a more personal way how collaborative, stepped care is helping people in Washington state communities.

Stories from the King and Pierce Counties Disability Lifeline Integration Pilot: Coordinated Care between Community Health Centers (Level 1) and Community Mental Health Centers (Level 2)

A middle-aged woman with a long work history at a major Seattle employer became emotionally unstable and unable to work, after some years of increasingly inconsistent at work. Her primary care provider referred her to a Disability Lifeline mental health care coordinator, who recognized a severe mood disorder and organized a treatment plan in coordination with the primary care provider and consulting psychiatrist. After two months of treatment, she has had significant improvement in her mood symptoms and ability to function. Through close follow-up with the care coordinator, she has close medication monitoring, has been able to make and keep important medical visits, and has completed the paperwork that will provide her long-term disability funding along with stable medical and mental healthcare.

A shared registry provides pertinent information about clients’ progress among treating providers from both primary care (Level 1) and community mental health agencies (Level 2). A behavioral health specialist at a primary care clinic was excited to learn that a Disability Lifeline client she had evaluated was referred to a mental health agency, had been evaluated by the Level 2 psychiatrist, and has had several housing and other referrals. The client was recently approved for GA-X and the Level 2 case manager is working on getting an outpatient mental health benefit through the RSN.

After looking at the contact notes in the shared registry, another Level 1 care coordinator was pleased to learn that her client, who has been diagnosed with schizoid personality, had completed several sessions with the Level 2 case manager. The client, who is homeless and has been visiting the clinic for twelve years, is now enjoying staying at a shelter despite being previously opposed to the idea. The case manager is continuing to put him on the shelter list each morning.

A Level 2 case manager wrote the following report:

“I just wanted to share with you a recent success with our client. With his permission, I have been in contact with his older sister in eastern Washington, keeping her updated on his current situation and his safety. The client finally gave me permission to invite her to a session.... My client’s three adult children (also estranged) will be invited next, but that will probably happen after we conclude our work together. This is what we want for our clients, the opportunity to practice skills on their own.

I have also shared his progress with his Residential Services case manager and his HUD Housing case manager at the apartment that we were able to get for him. He has really bonded with his HUD case manager and she was delighted to hear of his progress. His apartment will be ready in a couple of days; he is definitely ready for this new, independent chapter in his life.

I have hooked him up with an employment specialist at Goodwill, who places individuals 55 and older in the community for job training/work. This is a government supported program, so he can earn money on top of his Disability Lifeline benefit. He is really looking forward to having his life back, earning some money, having his own place, and having some honor and dignity in independent living."

Stories from King County’s Maternal and Child Behavioral Health Pilot:

Country Doctor Community Health Centers was an early adopter and strong performer among eight Maternal and Child Behavioral Health pilot clinics, which began in May 2009. Currently carrying a full mental health caseload of women and children at its two Seattle clinics, Country Doctor shared the following success story achieved through this project:

“Maria” (real name has been changed) is a Spanish-speaking mother to a 1-year-old girl and a 6-year-old boy. She has been a patient at Country Doctor Clinic for both of her pregnancies and always appeared to staff as a well-groomed, high-functioning mom who is cheerful and friendly. However, in September 2008, Maria completed her first PHQ-9 screening and scored at a level that is indicative of major depression, requiring treatment through psychotherapy and/or antidepressants.

Social work staff contacted Maria shortly after the screening and provided an in-person appointment for further clinical assessment, to offer support and discuss treatment options. With a referral from the social worker, Maria met with the clinic’s behavioral health specialist one week after the assessment. She also consulted with her doctor in early October.

The primary care team created a patient care plan that included a low-dosage of antidepressant medication, regularly scheduled meetings with the behavioral health specialist, and less frequent meetings for medication management. Maria’s 6-year-old son was also screened for behavioral concerns.

The provider team consulted with a psychiatrist from the UW Department of Psychiatry, who reviewed the treatment plan for Maria. The psychiatrist was in frequent contact with the clinic team via phone and email; consultations were organized through the shared patient registry that captured key information about mental health treatment and utilization.

The social worker also shared information about parenting classes and child development, as Maria requested. Maria was one of the first members to attend Country Doctor’s Spanish-speaking peer support group for pregnant and parenting women, which began in October 2008. Maria remains a dedicated member of the support group and now brings her younger sister to the group.

While Maria still struggles with depression from time to time, she remains engaged in treatment, is learning important coping techniques, and is caring for her children well. Her most recent scores on the PHQ9 indicate that her symptoms of depression have largely abated.

Stories from King County’s Coordinated Program for Veterans and their Families:

HealthPoint Community Health Centers partners with Valley Cities Counseling and Consultation to provide coordinated, stepped care to eligible military personnel and their families in south King County. HealthPoint shared the following success story achieved through this project:

A 58 year old African American woman named “Sheila” (name has been changed) was referred by her HealthPoint primary care provider to the mental health care coordinator. She had a long history of fibromyalgia and chronic pain and was on pain medication as well as several other medications. At her initial assessment, her PHQ9 score was extremely high, indicative of severe depression. She was in a stressful job and also suffered from anxiety. She had a history of sexual abuse and substance abuse.

This patient was also a Navy veteran who had developed a debilitating drug addiction and was discharged after seven years of service. Shortly after discharge, she opted for substance use treatment but has continued to struggle with addictions.

The HealthPoint care coordinator worked with the patient on overcoming her depression. They have addressed her past trauma, chronic pain, and substance use, all of which are triggers for her depression. After five months of care, the patient’s PHQ9 score has dropped to a low score indicating that depression symptoms were no longer present.

She is taking charge of her situation, including job searching and selling her condo. Her fibromyalgia has been reduced to a few short episodes each week and she has reduced her pain medication use. At her first appointment she walked in slowly, crouched over, and leaning on a cane. At her last appointment, she rode her bike to the clinic.