Collaborative care model significantly improves patient outcomes

Feb. 13, 2016

In 2010, a University of Washington study in the New England Journal of Medicine described a collaborative care model that improved outcomes and quality of life for patients with depression and coexisting diabetes or cardiovascular disease. The landmark study added to a growing body of evidence that such care models can significantly benefit people with chronic mental and physical conditions while holding the line on costs or even reducing them.

Despite this, collaborative care management is rare in primary medicine. To determine whether integrative care could be successful across varied settings, a consortium of 10 organizations developed the Care of Mental, Physical and Substance Use Syndromes (COMPASS) model.

Initiated in 2012, COMPASS aims to improve the quality, experience and affordability of care for community-dwelling adults who have depression and chronic comorbidities — a population with disproportionately high health care costs and an increased risk of complications and premature death.

"COMPASS is a national implementation and dissemination project that takes a model shown to work in research to see if it works on a larger scale," explains David J. Katzelnick, M.D., a psychiatrist at Mayo Clinic's campus in Rochester, Minnesota.

Eighteen medical groups are involved in COMPASS nationwide, including Mayo Clinic and Mayo Clinic Health System locations in Minnesota and Florida. All target patients who have depression plus heart disease or diabetes. Many of these patients see a primary care provider, but only about half are diagnosed with depression and only half of those receive treatment. Most who are treated don't experience much improvement.

"We know that comorbid psychiatric problems play a big role in patient complexity and prevent patients from getting better medically. In the COMPASS model, psychiatry and medicine join forces to deliver improved care for both mental and physical diseases simultaneously," Dr. Katzelnick says.

How COMPASS works

COMPASS draws on the best practices of several collaborative care models, including Wagner's Chronic Care Model, the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program and TEAMcare.

Key components of COMPASS include:

  • A care coordinator, usually a registered nurse, who meets with patients weekly to monitor their condition and provide support and active follow-up
  • A consulting psychiatrist and primary care provider who review problem cases with the care coordinator on a weekly basis and make treatment recommendations to the primary physician
  • A computerized registry, ongoing data analysis and quality improvement

"The critical component is the systematic case review, when the psychiatrist, care coordinator and physician expert work together to identify patients who aren't doing well and need more than primary care can provide," Dr. Katzelnick says. "Together they determine what might be done to help a particular patient get back on track.

"There are many dramatic stories of patients who have been referred to the COMPASS program because they are depressed, have frequent hospitalizations and aren't getting better. The families, the primary physicians and the patients themselves may have given up. But once the COMPASS team figures out what is needed, there often is a complete turnaround. When depression is effectively treated, patients become more actively involved in their own care, they eat better and start to exercise, and then their diabetes, heart disease and quality of life improve, too."

Care coordinators, who must have a keen ability to connect with and motivate patients, are essential to the success of the program. "Many patients aren't interested in walking more or eating less salt or taking medications. The care coordinators work to discover what patients do care about and work with them to set up self-management goals. Patients become very connected to their care coordinator, feeling that this is one person who hasn't given up on them," Dr. Katzelnick explains.


The COMPASS project officially ended in July 2015, but it has been so successful that many participating centers are continuing it, often combining it with other programs. At Mayo Clinic, a modified version is now part of the Mayo Model of Community Care.

"The results have almost equaled those in the University of Washington randomized trial," Dr. Katzelnick says. "For the 750 enrolled patients at Mayo, A1C and LDL levels are down, hospitalizations have been substantially reduced, and although the final numbers aren't yet in, it looks as if costs have been cut by more than $1,000 per patient."

The challenge, he says, has always been knowing how to implement the results of research studies in real-world settings. "The point of research is to take things we know work and get them as quickly as possible to people who are suffering. COMPASS has accomplished this," he says.

For more information

Katon WJ, et al. Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine. 2010;363:2611.