In California, one in five people experience perinatal mood and anxiety disorders (PMAD) and many women are under identified or undertreated despite available effective treatments. The Los Angeles Maternal Mental Health Access (LAMMHA) program is working to change that by helping LA County community health centers implement the evidence-based Collaborative Care Model (CoCM) for perinatal mental health. Implementing a complex new model takes interdisciplinary collaboration, training, and ongoing listening, learning, and real-time adjustments.
A new study under peer review from the LAMMHA evaluation team examined what the program learned using a rapid audit-feedback method from its first cohort of four federally qualified health centers (FQHCs) in relationship to the process of implementation. Guided by the Consolidated Framework for Implementation Research 2.0 (CFIR) and Woodward Health Equity domains1, the Stages of Implementation (SIC) tool was used to track progress, timing, and completeness across phases of implementation. Information was simultaneously gathered from interviews with clinic staff, clinicians, and practice coaches supporting each clinic, and from site visit observations. Merging these data sources, six key areas were identified as important to address for implementation of CoCM for perinatal mental health in community clinic settings.
Six Early Lessons in Perinatal Mental Health CoCM Implementation:
- Early engagement is key. Sites needed more time before launching care than originally anticipated to identify and engage leadership and clinic champions and clarify team roles and responsibilities. Involving site-level clinic directors and department champions in the very beginning is beneficial to the overall process.
- The postpartum care transition is a challenging reality. Patients often moved from OB or midwifery care to a primary care provider after delivery, making it hard to maintain continuity of behavioral health support. Stronger referral pathways across care settings and clearer handoffs are critically important.
“That postpartum transition is a really challenging one. So much of LAMMHA is contingent on having continuity with the primary care provider.”
– LAMMHA clinic team participant
- Finding reproductive psychiatric consultants is hard. A shortage of available reproductive psychiatrists, unclear hiring responsibilities, and high costs made staffing the CoCM psychiatric consultant role a common barrier to getting started. Clinics and implementation coaches should anticipate this, and coaches should offer clinics guidance and brief support documents early on to aid the process.
“Luckily, we also have an in-house psych person, so we didn’t have to find someone from outside. We were able to allocate a lot of money to these other ancillary roles instead of a psychiatric consultant, because our worry was, ‘if we are going to use all this grant for our psychiatrist, what’s going to happen?’ It was really helpful to have that in-person psych involvement.”
– LAMMHA clinic team participant
- Data infrastructure takes time to get right. Integrating screening tools and patient registries with existing electronic health records took time and creative troubleshooting. Additional workflow steps and questions about data privacy with external systems were areas where some sites needed more time and support.
- Reframing support matters. Renaming “site visits” to “coaching visits” was important to signal more collaboration and support for clinic teams rather than oversight and evaluation.
- Billing Needs expert attention from the start. Sustainable billing for CoCM is especially complicated in California, where care coordination outside of face-to-face visits cannot be billed under CoCM codes. Because care coordination is a core feature of the model, clinics need dedicated billing guidance early to understand which strategy is most sustainable for them.
“In California, it is a little tricky just because clinical sites can’t bill for any interactions that are not face-to-face time – which is supposed to be the benefit of collaborative care – because there is so much documentation and reviewing the caseloads. [Billing for care coordination] frees up more time with the patients to actually do the work. But in California, we don’t have that benefit. For the most part, the clinics are just continuing with their psychotherapy codes. I think that’s something to know for future improvements if we could understand that further or have more of a layout before implementing with future cohorts.”
– LAMMHA clinic team participant
Rapid-Audit Feedback in Action
The LAMMHA program’s responsiveness to real-time feedback, identified through implementation tracking using the SIC tool, coaching visits, and interviews with clinic teams and practice coaches, led to concrete changes for future clinic cohorts:
- Referral pathways were strengthened to improve postpartum continuity of care across clinical settings.
- Site visits were reframed as “coaching visits” to emphasize support to clinic teams over evaluation.
- Coaching enhancements around finding and contracting with psychiatric consultants who are adept at weaving into a CoCM were developed including a guidance document to support clinics in this search.
- Dedicated Medi-Cal (California’s Medicaid program) billing experts were onboarded to help sites identify sustainable billing strategies.
Staffing the psychiatric consultant role, expanding pre-launch preparation time with more structured onboarding, and data infrastructure remain important areas for continued innovation. Emerging models such as ad-hoc psychiatric consultation lines (e.g. PROMISE) offer additional approaches to help bridge psychiatric staffing challenges within CoCM and merit further investigation. Importantly, the CoCM case review and relationships between care team members necessary for CoCM cannot be supported by psychiatric consultation lines, but they could be useful until a site dedicated CoCM psychiatric consultant could be hired. Due to existing perinatal mental health screening mandates in California, seamless integration of patient tracking registries (an essential component of CoCM) into existing systems is also an important priority. Doing so will help close gaps in screening, identification, regular follow up, treatment, and remission of perinatal mental health disorders.
Each of the lessons learned in the first LAMMHA cohort influenced ongoing implementation with new cohorts. Using the SIC and structured rapid qualitative review, the LAMMHA team was able to understand how implementation processes could be adapted to meet clinic needs, enhancing the success of both current and future cohorts.
LAMMHA is a five-year program funded by The California Health Care Foundation (CHCF) to support Los Angeles County community health centers in the identification and treatment of common perinatal mental disorders in primary care. For more information or to apply for an upcoming LAMMHA cohort, visit the CCALAC LAMMHA program page and our previous blog posts on the LAMMHA program and the LAMMHA ECHO series.
*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).
Citations:
- Woodward, E.N., Singh, R.S., Ndebele-Ngwenya, P. et al. A more practical guide to incorporating health equity domains in implementation determinant frameworks. Implement Sci Commun 2, 61 (2021). https://doi.org/10.1186/s43058-021-00146-5
Co-authors:
Dana Beck, PhD, MSN, MS, FNP-BC
Assistant Professor
School of Nursing
University of California, Los Angeles
Theresa Hoeft, PhD
Research Assistant Professor
Department of Psychiatry and Behavioral Sciences
University of Washington
Cassia Brockway, MPH
Practice Transformation Consultant
Elevation Health Partners
Amritha Bhat, MD, MPH
Perinatal Psychiatrist and Associate Professor
Department of Psychiatry and Behavioral Sciences
University of Washington
Ian Bennett, MD, PhD
Physician Supervisor
Family Health Services FQHC
Solano County Department of Health and Social Services