Implementing the collaborative chronic care model for mental health: a nonrandomized clinical trial

Collaborative chronic care models (CCMs) are an evidence-based way to structure care in outpatient mental health settings. This project investigated whether implementation facilitation (IF) can enhance CCM-consistent outpatient mental health care and reduce mental health hospitalizations compared with centralized technical assistance (CTA).

This was a stepped wedge hybrid 2 implementation-effectiveness trial in outpatient mental health clinics at eight US Department of Veterans Affairs (VA) medical centers (four waves, two sites each) conducted from 2022 to 2024. Staff participants included clinicians involved in delivering team-based outpatient mental health care. The patient sample consisted of US military veterans treated by 42 participating mental health teams. IF was used for 8-9 months to increase alignment with CCM principles at each participating site. All the sites (including eight comparison sites that were nonrandomized but matched on key variables) had access to CTA. The coprimary outcomes were (a) alignment with CCM-based care evaluated using the Role Clarity and Team Primacy subscales of the Team Development Measure [TDM], and (b) mental health hospitalizations extracted from the electronic health record during the year following initiation of IF.

The sample included n = 20,835 patients at participating sites and n = 60,221 patients at comparison sites. The pre-implementation TDM was completed by 134 staff members, and post-implementation TDM was completed by 109 staff members. Role Clarity and Team Primacy subscales of the TDM demonstrated small, nonstatistically significant improvement after completing IF (p = 0.33[t-value: 0.97] and 0.14 [t-value: 1.48], respectively). Multivariate generalized linear mixed models indicated participating sites had similar mental health hospitalization rates following IF initiation compared to sites receiving CTA alone.

This trial revealed that IF to enhance CCM-consistent clinical practices in outpatient mental health teams was associated with small improvements in team functioning that did not achieve statistical significance. Mental health hospitalization rates did not differ for sites using IF versus CTA. TDM-based assessments of team functioning at baseline were similar to post-implementation results from a prior trial, suggesting that CTA to support team-based care may have increased team functioning in these settings prior to trial initiation.

NCT05997836. Retrospectively registered 18 August 2023: https://clinicaltrials.gov/study/NCT05997836?term=NCT05997836%26rank=1 . Ethical approval: This evaluation was conducted as a quality improvement activity for VA and was deemed by the R&D Committee at the VA Boston Healthcare System not to be research; therefore, it was not subject to IRB review.