Interprofessional Collaborative Practice: Management of Chronic Disease and Mental Health Issues in Primary Care

Abstract

This case study describes the process of implementing and evaluating an interprofessional collaborative practice (IPCP) program for primary care and behavioral health integration focused on chronic disease management. The result was a strong IPCP program in a nurse-led federally qualified health center serving medically underserved populations. The IPCP program at the Larry Combest Community Health and Wellness Center at the Texas Tech University Health Sciences Center spanned >10 years of planning, development, and implementation, supported by demonstration, grants, and cooperative grants from the Health Resources and Services Administration. The program launched 3 projects: a patient navigation program, an IPCP program for chronic disease management, and a program for primary care and behavioral health integration. We established 3 evaluation domains to track the outcomes of the program: TeamSTEPPS education outcomes (Team Strategies and Tools to Enhance Performance and Patient Safety), process/service measures, and patient clinical and behavioral measures. TeamSTEPPS outcomes were evaluated before and after training on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Mean (SD) scores increased significantly in team structure (4.2 [0.9] vs 4.7 [0.5]; P < .001), situation monitoring (4.2 [0.8] vs 4.6 [0.5]; P = .002), and communication (4.1 [0.8] vs 4.5 [0.5]; P = .001). From 2014 to 2020, the rate of depression screening and follow-up improved from 16% to 91%, and the hypertension control rate improved from 50% to 62%. Lessons learned include recognizing partner contributions and the worth of each team member. Our program evolved with the help of networks, champions, and collaborative partners. Program outcomes show the positive impact of a team-based IPCP model on health outcomes among medically underserved populations.

Keywords: behavioral health integration; chronic disease management; interprofessional collaborative practice.

Figure 1.

Patient workflow for clinic visits with the IPCP team, Larry Combest Community Health and Wellness Center, West Texas, 2019. GAD-7 is a self-reported questionnaire for screening and severity that measures generalized anxiety disorder with 7 items. PHQ-9 is a self-reported diagnostic tool to screen patients in a primary care setting for the presence and severity of depression. Abbreviations: GAD-7, General Anxiety Disorder–7; IPCP, interprofessional collaborative practice; PCP, primary care provider; PHQ-2, Patient Health Questionnaire–2; PHQ-9, Patient Health Questionnaire–9. ^a Patients with difficulty accessing care (eg, no transportation, no health insurance) will be referred to community health workers for enabling services, which include scheduling free transportation, providing prescription assistance, applying for Medicaid/Medicare/other financial support, providing chronic disease management education, and coordinating care. ^b Patients with chronic diseases will be referred to the PCP for regular follow-up visits. ^c Patients with potential depression or anxiety based on screening scores will be referred to either psychologists or clinical social workers for follow-up diagnosis and treatment.

Figure 2.

Depression screening and follow-up rates, hypertension control, and diabetes control, Larry Combest Community Health and Wellness Center, West Texas, 2014-2020. Data source: Uniform Data System.