The Los Angeles County Maternal Mental Health Access (LAMMHA) program is a five-year program funded by The California Health Care Foundation (CHCF) to support community health centers in the identification and treatment of urgent but common perinatal mental disorders in primary care. The first cohort of clinical teams from AltaMed Health Services and Eisner Health shared their experiences as they near completion of their two-year experience in implementing the evidence-based collaborative care model (CoCM).
Why did your organization join the LAMMHA project? What were some of the big benefits of your participation?
Eisner: Our primary reason for joining the project was to increase mental health access to our prenatal and postpartum patients. We believe we have met these goals, as we were able to reach these patients and more often provide them with in-house services versus having to refer them out. Now, we only refer out as needed. One big win with this project is patients being able to work with one provider throughout their pregnancy. This continuity of care has resulted in a smoother experience for patients
AltaMed: AltaMed joined the program to implement a process for a population that is under resourced in our community. This was an opportunity to shed light on a huge need to provide support and services to our birthing population. Through LAMMHA participation, AltaMed obtained support from our health center teams and leadership, developed a new referral queue and workflows, and developed reports to verify the services being used and ensure we are identifying patients in need of care.
As a Pediatric Provider, it is fulfilling to see mom’s emotional state and mood improve at baby’s appointment time. I just had a mom last week that admitted to feeling sad and wanted to receive services. Cases like this make me happy because there’s an opportunity for mom to reach out for help anytime.”
– Eisner Pediatric Provider
What are some patient success stories from implementing the LAMMHA model?
Eisner: One patient experiencing intense anxiety after giving birth was ambivalent about psychiatric services at the beginning of their time in the program. They continued receiving behavioral health services, and due to the rapport with their provider and the patient’s anxiety not easing, they decided to give medication a try. With medication, psychiatric consultations, and continued behavioral health service, the patient greatly improved and reported a drastic decrease in their anxiety.
AltaMed: One patient success story was a 33-year-old female who completed treatment with no medication, only therapy. The patient presented with both depression and anxiety symptoms. At intake, the patient had a PHQ-9** score of 14 and a GAD-7*** score of 11. During the treatment sessions the patient was very engaged and proactive on practicing any techniques discussed. The patient started to work on creating healthy boundaries, worked on using coping skills that made her feel good about herself and helped her adjust to her changes. The patient and the clinician worked on building rapport and some skills such as meditation, deep breathing, and journal writing. There was a shift in the patient’s confidence due to using these techniques. The clinician noticed confidence in her motherhood as well. At the closing session, the patient was managing symptoms and was ready to practice her skills on her own. After intake, eight sessions and a closing session, the patient’s PHQ-9 score was 3 and GAD-7 score was 2.
What were some of the challenges you experienced during program implementation?
Eisner: As we are still referring to psychiatric services outside of LAMMHA as needed, we hope to smooth out the referral process. We have found that we need to work on education and outreach on certain medications for our staff and providers, as there is some hesitancy in engaging with patients when they are taking medications that staff and providers aren’t as familiar with. Our team found that the ECHO sessions were helpful in content but were sometimes hard to engage in due to the lunch-hour timing. Our team also found that staying up to date with medication-related resources was extremely helpful.
AltaMed: A challenge we encountered early on was with training, as we had to focus on training staff from both participating clinical sites. This continues to be a challenge due to staff turnover. The leadership and supervisors need reminders to train new staff to have everyone follow the same workflow. Another challenge we encountered was ensuring the accuracy of the PHQ-9 data as we had to review the data with other departments several times to complete the PHQ-9. Another barrier was pulling data for the pediatric PHQ-9 that was completed at the well-child visits for the birthing parent. This is something we continue to struggle with as the workflow is new to the team. We will continue to inform our clinic teams and encourage the leadership and supervisors to review workflows. Funding for collaborative care has also been a challenge. Federally Qualified Health Centers are not able to bill for behavioral health visits on the same day as a medical visit. Developing a process for billing continues to be a challenge.
Are there any insights and tips you can share for other organizations that may be interested in implementing the Collaborative Care Model?
Eisner: It is extremely important for providers to engage in pharmacological therapy work if they are not doing so already. We found that some of our providers were initially hesitant to engage in work with medications they weren’t as familiar with and didn’t feel like they had support or enough information. More opportunities for education, as well as more opportunities to consult with psychiatric providers can help ease this hesitation.
AltaMed: A few tips we can share to help other sites interested in implementing the model:
- Continuously train and review workflows with your teams.
- Seek opportunities to learn more about working with the perinatal populations.
- Consult with your providers, psychiatric consultant, and supervisors to continue to learn and expand the program.
- Work closely with your quality improvement and billing teams.
- This is a program that will change and evolve as you learn more and what is the best fit for your patients. Be flexible and patient.
Have the LAMMHA program advertised during OB visits via flyers or a chalkboard in each exam room with brief LAMMHA info such as, ‘feeling depressed, talk to your MA or provider, we are here for you.’ Have the name and ways to reach the social worker in case the patient is shy and would rather just reach out on their own.”
– Eisner Pediatric Provider
It has been very rewarding to see our patients improve as a result of them getting the help they need! Increasing access to service and decreasing stigma has been a great experience for our team. Moving forward, we are considering scheduling times for Integrated Behavioral Health (IBH)**** and providers to discuss cases in-person. Informal huddles were happening and EHR communication was occurring, but an official in-person time to meet could be beneficial and help our team best meet our patients’ needs.”
– The Eisner Team
This program has enabled us as OBGYN providers to offer more comprehensive mental health care to pregnant and post-partum women. It has helped to improve the quality of life for so many women who are suffering from antepartum and postpartum depression, and has opened doors for women to have continuity of care with therapists and providers so that we can all work together to provide holistic care for women and their newborns.”
– AltaMed OBGYN Provider
Selected available resources to support CoCM implementation & sustainment activities:
LAMMHA Resources
LAMMHA ECHO Training Series
UW AIMS CoCM Office Hours
UW AIMS Quarterly CoCM Webinar Series
UW AIMS Registries for CoCM Caseload Management
UW AIMS Pediatric CoCM Guide
UW AIMS CoCM Billing Guides
APA Videos: Using the Collaborative Care Model for Special Populations
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During the two-year program, the participating LAMMHA clinics receive intensive on-going support and training to implement and sustain CoCM. For more information, please visit the CCALAC LAMMHA program page and see our previous blog posts on the LAMMHA program and the LAMMHA ECHO series. For more information and resources around maternal mental health in California, please visit the California Department of Public Health – Maternal Mental Health page.
*LAMMHA program partners: Community Clinic Association of Los Angeles County (CCALAC), Elevation Health Partners (EHP), Maternal Mental Health Now (MMHN), Concert Health, University of Pennsylvania (UPenn), University of California, Los Angeles (UCLA) and the Department of Psychiatry and Behavioral Sciences at the University of Washington (UW).
** Patient Health Questionnaire (PHQ-9) is a diagnostic tool used to screen adult patients in a primary care setting for the presence and severity of depression.
*** Generalized Anxiety Disorder scale (GAD-7) is a widely used self-administered diagnostic tool designed to screen for and assess the severity of generalized anxiety disorder.
**** Integrated Behavioral Health (IBH) is a collaborative approach to healthcare that combines medical and behavioral health services within the same setting.