A Collaborative Care Lexicon for Asking Practice and Research Development Questions
A National Agenda for Research in Collaborative Care
C.J. Peek, Ph.D.,a Department of Family Medicine and Community Health, University of Minnesota Medical School
The Collaborative Care Research Network (CCRN), a sub-network of the American Academy of Family Physicians National Research Network and a practice-based research network, was formed to develop and implement a national, practice-based research agenda to evaluate the effectiveness of collaboration between behavioral health/substance abuse clinicians and primary medical care clinicians. Although research to date generally confirms positive outcomes from collaborative care, it is not clear just what components or methods account for those positive outcomes. Funding agencies and policymakers would like to know that so they can make focused investments in this area, particularly in context of the patient-centered medical home. The CCRN is designed to pose and answer such research questions in a way that can be understood consistently across geographically diverse practices. But experiences framing such research questions led to confusion about the meanings of terms in common use, especially regarding the components or dimensions of collaborative care that are the subject of research questions. Funding agencies and policymakers need consistently articulated concepts for this new scientific field rather than the highly variable language for these concepts presently in use. This lexicon or conceptual system for the field was created and used to formulate research questions as a product for Agency for Healthcare Researchand Quality (AHRQ). Such conceptual clarity, or pre-empirical work, has preceded the empirical triumphs we associate with mature scientific fields and is expected to release much more focused energy for empirical investigation in this field as well.
Introduction: A Place in a New Movement for an Old Idea
Today's foment in the field of healthcare is both exciting and confusing. New ideas in healthcare come forward while old ideas find renewed meaning in new contexts. The pace and intensity of conversation and experimentation intensifies as unsustainable costs and escalating concerns with quality, insurance coverage, and patient experience intensify. Thanks in large part to these pressures, interest in the concept of "patient-centered medical home," "health care home" or "advanced primary care" (all synonyms) has been exploding. This concept invokes whole person/patient-centered care, care coordination, and attention to psychosocial factors (Rosenthal, 2007; Nutting et al, 2009; Cutler, 2010). In turn this has breathed renewed interest into a forty-year-old subfield whose subject matter is improved integration of biomedical and psychosocial healthcare—or more specifically "medical-mental health integration" or "collaborative care." The same or similar subject matter also is called "integrated care," "shared care," "co-located care," "primary care behavioral health," "integrated primary care," or sometimes "behavioral medicine"—and this is just a start. Each of these terms encompasses a similar core of subject matter for implementation and study. But each of the names for that subject matter has emerged from different practice, intellectual, geographical or disciplinary traditions—as if dialects of a more general language loosely understood by insiders or "native speakers" in that field. To find a meaningful place in the patient-centered medical home (PCMH), the field of collaborative care must not only show its effectiveness empirically, but become a field more consistently and widely understood in language and practice by the public and the practitioners themselves.
The field requires more consistent language today than in the past. The field requires more than loose insider vocabulary, more than the dialects of local collaborative care pioneers and implementers. To enter the mainstream of the PCMH, collaborative care requires a consistently understood set of concepts and language for basic terms and foundational elements. Such language must help everyone navigate the subject matter in a consistent and precise enough way to enable the practical work of:
- Practice redesign shaped by.
- Performance evaluation leading to.
- Patient engagement; and sustained by.
- Policy and business model change.
Researchers, system designers, quality improvement and performance measurement experts, and policymakers require a common language. Of course, so do patients and citizens who are supposed to participate in and benefit from the experience of collaborative care and to know what they are "buying" when they choose clinics and health plans.
Inconsistent understanding of core concepts in collaborative care is far from a theoretical concern. For example, in planning the Research Development Conference for Collaborative care in 2009 (Miller, Kessler, and Peek, in this volume), very practical concerns pointed to the need for a common language or lexicon. Building on decades of previous clinical and research explorations, research funders, policymakers, and others trying to redesign healthcare have become increasingly interested in collaborative care as a means to accomplishing the larger goals of primary care or of the PCMH. But as their voices were heard during research agenda planning, they often indicated that collaborative care clinicians and advocates seemed to be "all over the map", even naming their field inconsistently. To them, it felt more like encountering a cacophony of individual voices without a structure of shared concepts rather than talking with a group using a consistent framework for their subject matter. While policymakers and research funders remained persuaded by the potential value of collaborative care, they felt handicapped in advocating for it publicly or behind the scenes because of the perceived lack of consistency or rigor of the concepts in use. The composite message received leading up the conference was, "It would help if you all talked about the components and terms of your field in a much more consistent way than you do now."
Consistent Language for Research in Collaborative Care
While systematic review of many years of research in collaborative care is globally positive (Butler et al, 2008), it has not been able to point specifically at what components or active ingredients are getting positive results when they occur. Consequently, the national research development conference was needed to create that research agenda. But even in conference planning conversations, people stumbled over language—with conference calls slowed down by observations such as "I'm not sure we mean the same thing by that," or "I thought I understood where you were going 5 minutes ago, but now I don't think we meant the same thing by X," and "I wonder if what I call Y you call Z, and if there is really any difference." In a starter list of research questions brainstormed by the committee, the terms "continuum of integration," "extent of collaborative care components," and "degree of collaborative care" appeared—along with a conversation about whether these are the same and whether anyone would know how to measure them. It became very difficult for the program committee to formulate an initial series of unambiguously understood research questions for collaborative care that could be examined, refined, or replaced by the broad audience invited to the research conference. The following questions arose:
"Do we have a good enough shared vocabulary (set of concepts and distinctions) for asking research questions together across many practices? Do we mean similar enough things by the words we use or how we distinguish one form of practice from another for purposes of investigating their effects? Do we have a shared view of the edges of the concept we are investigating—the boundaries of the genuine article or the scope of our subject matter? If we don't share enough of that vocabulary, we will think we are asking the same research questions, using the same distinctions, conducting the same interventions, or measuring the same things—but we won't be—and will confuse our network practices and our funding organizations..."
Confusion over terms in collaborative care typically takes two forms.
Meanings of commonly used terms. What are the differences between mental health care and behavioral health care? What are the differences between collaborative care, integrated care, integrated primary care, shared care, coordinated care, co-located care, and consultation/liaison? These and other common terms frequently stopped conversations while individuals in the group tried to verify what others meant when using a particular term. As a result of these conversations a literature-based "family tree of related terms in use in the field of collaborative care" was created and appears in Figure 1. This was relatively easy to do and served as a common dictionary for the planning committee. But that was just the beginning.
Necessary components of collaborative care. What actually has to be in place for a particular practice to be regarded as doing collaborative care? This was by far the more difficult challenge and would not be met by the "family tree of terms." It is all too easy for a practice, a clinician, or an administrator to say, "Collaborative care—yes we already do that. We have a social worker in the hospital and a psychiatrist across town on our referral list." But for many on the program committee, this would not count as a genuine instance of collaborative care. But on what basis? Who says? What is the package of functional components that we all agree is necessary for a particular practice to be doing collaborative care? This was important for many reasons—identifying genuine instances of collaborative care in practice, identifying differences between those genuine instances, knowing what practices should or shouldn't be recruited into a collaborative care research network, and of course knowing what you are buying and what functions you want to support if you are designing a system, payment model, or public policy.
Without common language for the subject matter of collaborative care and what counts as the genuine article, creating a national research agenda and other developmental tasks for this field would be difficult to accomplish. Without common language, little practical work in the field would likely be accomplished on a meaningful scale in short timeframes, and instead would take place slowly in isolated pockets using localized dialects—something that had characterized the field up to that time. One of the conference tasks would have to be creating a usable "lexicon" or system of concepts for this newly rediscovered field.
Conceptual confusion is a normal stage for developing fields. The CCRN research conference planning committee decided it had to sharpen the concepts and language used in the field if it was to successfully create a research agenda—the "deliverable" of the AHRQ-funded conference—and increase rigor and consistency in the way this field is portrayed among not only researchers, but clinicians, administrators, payers, employers, policymakers, and patients themselves. All mature scientific or technical fields have lexicons (systems of terms and concepts) developed to allow collaborative and geographically distributed scientific, engineering, or applications work to take place. Systematically related concepts have an esteemed place in the history of mature fields that we now take for granted, e.g., electrical engineering, physics, and software development—and have enabled them to become mature sciences or technologies with associated empirical triumphs. In many cases the conceptual or pre-empirical development of these fields was done so long ago that we take it for granted and now see only the empirical achievements. But it takes a generally understood system of concepts and distinctions to do good science. Here is an example of lexicon development from 19th-century science:
At the time of the first International Electrical Congress in Paris in 1881, there were no fewer than 12 different units of EMF (electromotive force), 10 different units of electric current and 15 different units of resistance. The principal result of this first Congress was to give official endorsement to a proposal concerning the ohm and the volt. Ampere, coulomb and farad were also defined, all done as one conceptual system... Governments saw that it had become necessary for commercial transactions and trade to take quick, official, and common action about the very different units that were in use. Secondly, it appeared necessary to provide a forum of scientists, manufacturers, and learned societies. Its responsibility would be to study and to establish terminology for the whole field of scientific and technical concepts. (Excerpted from International Electrical Commission (IEC); www.iec.ch/zone/si/si_history.htm)
Without this system of electrical concepts becoming community property with standing across all electrical researchers, the field could not have developed into the mature form of empirical science that we now witness. But the effect was immediate: "The first Congress of 1881 has borne good fruit. It has not only brought about a rapprochement between electricians of all countries, but it has led to the adoption of an international system of measurement which will be in universal use." (From "The Electrical Congress of Paris, 1884". Nature 30, 26-27; 8 May 1884).
Electricity, physics, and other sciences had their stages of conceptual confusion, and all met the challenge by creating a consistent and practical set of concepts by which anyone could navigate the field and collaborate in practice and research. The program committee regarded this as a normal, respectable, and practical task for the field of collaborative care.
Historically, subject matters that include the terms "behavior," "mental health," "psychosocial," or "collaborative" in their names have stereotypically been seen as soft, subjective, or not as conducive to scientific investigation in the usual sense, despite the existence of extensive literature and research. Different published papers often employ disparate conceptual and language systems, and this can lead to a sense (especially as seen by those outside the field) that the field is not quite worked out or is being re-created by each author. As important as "behavior" is to contemporary healthcare and the medical home, there remains a sense that it is a fuzzy concept compared to traditional medical areas. The behavioral dimensions of health and healthcare not only entail studying immensely complex phenomena, but may be considered immature fields compared to their biomedical cousins. Creating a lexicon for collaborative care was seen as not only essential for success of the funded conference on collaborative care, but to begin to put at least some "behavioral" or "collaborative" language as it relates to primary healthcare delivery on a more systematic and consistent conceptual foundation that would be accessible to anyone.
Some contemporary observers (Ossorio, 2006; Bergner, 2006) have pointed out the need for widely accepted conceptual systems for use in behavioral fields and psychology—fields that ultimately encompass collaborative care. The connection between the conceptual and the empirical in the creation of psychology as a new scientific field is illustrated by the following excerpt from "An open letter from Isaac Newton to the field of psychology" (Bergner, 2006).
At the risk of offending, I should like in this letter to offer my principle hypothesis regarding why your field has not to date arrived at any manner of broadly accepted, unifying theoretical framework, and has not for this reason realized the scientific potential, importance, and respect it would rightly possess... You have understood aright the basic truth that science is ultimately concerned with how things are in the empirical world. However, you have neglected the further truth that often, as in my own case, much non-empirical work must be undertaken if we are to achieve our glittering empirical triumphs. To lament that you have not found your Newton is, of course, to state what seems widely agreed in your day: that your young science has not to date arrived at any manner of broadly accepted, comprehensive intellectual framework that accomplishes what I accomplished with my Principia...
In order to create the framework of the system of the world, it became apparent that some of the concepts at hand in 1665 would not suffice for my purposes. Thus it was that I set about to formulate a new system of concepts, all precisely defined and related one with another. In doing so, I determined that some of the then existing concepts were quite serviceable; "velocity" and "acceleration" come readily to mind in this regard. However, I found it necessary to formulate several new concepts. Thus it was that I formulated—dare I say I invented—the concept of "force." Further, I found it necessary to give new and different meanings to the concept of "mass" if it was to perform its needed function in my system. And so it was that I created, from parts old and new, a conceptual system that could draw the precise distinctions that I needed drawn to accomplish my objectives... (italics mine)
A Method for Creating a Lexicon for Collaborative Care
For a lexicon to become more than one person's invention for one limited study or application, it would need to serve the practical purposes of a broad range of people over a broad range of applications. This could not be created and published as an opinion by one person. But that is the usual approach to proposing definitions, and gives rise to the sense of cacophony that policymakers and researchers have noticed. Instead, a method for creating a lexicon with standing in the field would have to:
- Be consensual but analytic (a disciplined, transparent process—not a political campaign).
- Involve actual implementers and users ("native speakers" of the field, not only observers, consultants, and commentators).
- Focus on what functionalities look like in practice (not just on principles, values, goals, or visible 'anatomical features').
- Portray both similarities and differences (specify both theme and legitimate variations).
- Refine and employ existing familiar concepts that are serviceable to the extent possible.
- Be amenable to gathering around it an expanding circle of "owners" and contributors (not just an elite group with a declaration).
Fortunately, methods for defining complex subject matter that meet these requirements exist in the published literature—"paradigm case formulation" and "parametric analysis," as described by Ossorio (2006). The product is described later in this paper. It serves as a lexicon or, perhaps more accurately, an operational definition for posing collaborative care research and practice development questions described in the other two papers in this collection.
The process to create that lexicon was facilitated by this author in two stages—starting with a small core group of CCRN program committee members that consisted of Benjamin F. Miller, Gene Kallenberg, and Rodger Kessler. The present author then wrote a lexicon white paper that was used as a starting point for collaborative care vocabulary at the research conference and that serves as the basis for the present paper. A larger circle of contributors to this lexicon included research conference participants and those who attended a Collaborative Family Healthcare Association Conference presentation on this topic three weeks later. With their wisdom incorporated, the lexicon shown later in this paper became the organizing system for collaborative care research questions that were the product of the CCRN research conference submitted to AHRQ.
About definitions, paradigm case formulation, and parametric analysis. Before describing the product—the lexicon itself, it may be helpful to some readers to step back and contrast paradigm case formulation and parametric analysis with the usual approach to creating definitions. The usual approach to definitions is to create one or two sentences such as "collaborative care is X, Y and Z." Often creating definitions is pragmatic for the purposes of just one study or project. If a definition were created to structure the concepts for an entire field, it would attempt to identify genuine instances of collaborative care on the basis of uniformities in common across all those instances. But collaborative care is characterized not only by uniformities (a common core), but by many differences between instances of collaborative care. The definitional challenge is to develop a consistent shared language for both commonalities and differences without devolving into "anything counts." A simple one-sentence definition such as "collaborative care is X, Y, and Z" would likely be oversimplified, full of qualifications and exceptions, or considered wrong or incomplete by many.
For complex subject matters such as collaborative care, a paradigm case formulation is a better vehicle for creating a definition because it maps both similarities and differences at any level of detail desired. For example, the concept of "family" is also complex subject matter and would be very difficult to define in a single sentence that would satisfy everyone. The paradigm case formulation approach to definition of "family" starts with one archetypal statement (the paradigm case) that no one could possibly disagree with—and then goes on to systematically describe what could be changed (transformations of the paradigm case) and still be "family" (Figure 2).
In this example, the paradigm case and its transformations become the "definition" of family. Some may attempt to go back and substitute a one-sentence definition of the usual sort found in great diversity and abundance in dictionaries, in professional publications, and on the Web. But the limitations of the one-sentence definitions are why the paradigm case formulation method was employed for the collaborative care lexicon.
A complementary device, parametric analysis (understanding the dimensions of something), goes on to create a specific vocabulary for how one instance of collaborative care might be the same or different from another instance across town. In the "family" example, two of the parameters would be "number of children" and "number of parents." A simple illustration is shown below:
If you go to the lumberyard and ask for a 2x4, the person behind the counter will ask 3 questions:
- How long?
- What grade?
- What species?
If you say, "I need an 8-foot, #2, fir", they will go back into the stacks and get one. There is little left to say to specify a 2 x 4. These three parameters are the finite ways 2x4s can differ from one another. The parameters and some of the possible values for each parameter are illustrated in Figure 3.
A scientific example of parametric analysis is the specification and comparison of different colors employing the three parameters of color: brightness, hue, and saturation. Any color can be specified through supplying a value (as used in the scientific sense, not to suggest a value judgment) for each of these. (The values are defined in the Munsell color chart [Ossorio, 2006; pp. 35-36].) Parametric analysis is used to fine tune product design and market competitiveness parameters for industrial products and software because it allows the designer to measure the influence of all parameters on the outcomes desired—and the tradeoffs between them (Thieffry, 2008).
Parametric analysis sets the stage for comparative effectiveness research in collaborative care—in which one set of arrangements is tested against a different set. The "arrangements" are expressed through the parameters and the particular values of each parameter.
The Product—a Lexicon for Collaborative Care
The lexicon product used for the collaborative care research conference and as a structure for the resulting research agenda (go to Miller, Kessler, and Peek, in this volume) is described next, using two figures.
Paradigm Case Formulation
In Figure 4, a series of five clauses (with clarifying sub-clauses) describes one archetypal instance of collaborative care in action about which everyone in the group says, "That's an indubitable case of collaborative care in practice if there ever was one." Note that this is structured in a similar way to the definition of "family" shown in Figure 2. This is the consensual, non-controversial starting point.
The transformations listed beneath each clause describe the acceptable variations on the archetypal paradigm case that also qualify as collaborative care. This step is necessary to account for the legitimate differences between instances of collaborative care are—and to expand the range of what counts as collaborative care in practice. Transformations themselves were consensual, as were the clauses and sub-clauses.
This "paradigm case formulation" represents a definition of collaborative care that maps both the core concept and its acceptable variations—and therefore the edges of what in practice is considered genuine collaborative care for purposes of asking research and practice development questions.
Figure 4 is already a densely packed description, but this operational definition could be given as many "pixels" as needed to make the distinctions required for particular applications. For example, more specific definitions of terms that appear in the paradigm case formulation could be provided as needed for practical purposes, perhaps taken from the "family tree of terms" (Figure 1) or from other literature-based sources. Annotations could also be supplied that explain or clarify the reasoning, identify isolated exceptions, or clarify other questions that may arise during its use. For the purposes of this article, elaborations such as this are not included. Going the other direction, compact lower-definition descriptions of collaborative care that contain very few "pixels" could also be derived to suit other purposes, such as for an "elevator speech"—a brief description of the essence of collaborative care without the details.
In Figure 5, nine parameters—dimensions for describing differences—are used to show how one instance of collaborative care practice might legitimately be different than another one. Each parameter comes with a set of possible values. The reader will notice formal similarity to the parameters of 2x4s shown in Figure 3. Collaborative care is a more complex subject matter than 2x4s and hence contains more parameters and more complex alternatives for each parameter.
This parametric analysis is based on the similarities and acceptable differences expressed in the paradigm case formulation, but allows one practice to point, in a relatively simple concrete way, to how it is different from or the same as another practice. This can be useful in selecting practices that are similar enough to group for purposes of answering particular comparative effectiveness research questions and for practices to describe the particular focus and features of their own practice in specific terms. The parameters and/or paradigm case clauses could be turned into a practice profile or self-description by which practices could describe and compare themselves to others using consistently understood terms.
As with the paradigm case formulation, additional definitions, elaborations, or rationales could be supplied as needed for specific purposes. For example, research purposes will require specific metrics to accompany the cells in the parametric analysis—what you actually look at to decide what is going on in a particular practice (go to Kessler & Miller in this volume). For purposes of this paper, such elaborations are not included.
Reaction to the Lexicon White Paper at the CCRN Research Conference
Reaction to the white paper at the conference was mixed. Most participants expected to immediately start formulating research questions, not wrestle with nomenclature and concepts. Because the program committee had just experienced frustrating definitional confusions that would certainly arise at the conference, the lexicon task and agenda item was added out of necessity. This was frustrating to some participants and welcomed by others. Although the paper was described as dense or challenging by all, the lexicon was felt by most to be a major help—a shift toward a common understanding of the field and the ability to articulate consistently understood research questions. E-mails followed in the days after the conference expressing either appreciation for engaging the pre-empirical language issues in the field or frustration for delaying the formulation of empirical research questions. Other applications of this methodology have also revealed that doing such pre-empirical work (as Newton and the 19th century electrical researchers did in their fields) is initially seen as a distraction by some and as foundational by others.
Applications for the Lexicon
Asking Research Questions
The CCRN was formed as a practice-based research network for comparative effectiveness in collaborative care. That requires it to study practices doing different things and comparing the results. The lexicon helps in several ways:
Identify practices that qualify as already doing collaborative care. As said earlier, it is very easy for a practice to say in good conscience, "Collaborative care—we already do that." But when definition of the concept is fuzzy, there may be quibbles about whether that practice really does collaborative care. The paradigm case formulation establishes that definition publicly (via the paradigm case clauses and the parameters) so that practices can tell whether being recruited to the CCRN is appropriate for them. Moreover a practice that aspires to be part of the network but doesn't quite qualify, can see specifically what functional capacities to develop in order to do so.
Articulate (with sufficient definition) the comparisons to be made. For example, a research design might call for comparing different approaches to team composition and function such as the IMPACT (Unutzer et al, 2002) and DIAMOND (ICSI, 2008) approaches that use a consulting psychiatrist and a care coordinator vs. a generalist primary care behavioral health model (Strosahl, 1997) that employs an onsite mental health professional as a standard part of the medical team. Another example might be comparing otherwise similar practices supported by distinctly different business models. The parametric analysis supplies a three-level classification (pilot, project, mainstream) that allows researchers to choose cohorts of practices that are similar enough in that respect that their results can be meaningfully compared. These values can be further adjusted as the practical need arises for more (or fewer) distinctions.
Structure research questions and proposals. The papers in this collection framed the research questions using the vocabulary of the lexicon. This included 1) standard use of common terms found in the "family tree of terms," 2) a set of descriptive questions (What is really going on out there by way of collaborative care?) based in the clauses of the paradigm case formulation, and 3) a second set of evaluative questions using the parameters of collaborative care to help define the comparisons to make. The lexicon can then function as a consensus-based definitional reference for the terms and components listed in the research questions. Without that, it remains much more likely that the research questions will not be consistently understood across practices, investigators, or research funders.
The lexicon provides distinctions for asking consistently understood practice development, practice evaluation, and research questions, but measurable indices (metrics) are also needed to serve as quantitative measures, or approximations of otherwise qualitative descriptions of collaborative care practice contained in the lexicon. Such data elements are needed for comparative effectiveness research to actually take place (Go to "A Framework for Collaborative Care Metrics" in this volume).
Because of the variations in collaborative care practice, specific data elements and what should be expected to count as success will vary. But without a shared lexicon, choice of metrics may be regarded as subjective or arbitrary—as illustrated in these quotes from personal communications: "Metric discussions are being guided by the idiosyncratic opinions, experiences, and perspectives we each bring—and by who happens to be in which rooms during which discussions" and "everyone brings up their own favorite metrics". Because the lexicon identified both core features and acceptable differences it can help metrics conversations be systematic in these ways:
What is reasonable to expect depending on the target population under study (parameter 3). What benefit is expected for whom and exactly what data elements to include depend on whether the collaborative care practice is aimed at children or adults; at mental health conditions or chronic medical conditions or both; or at a specific disease or subpopulation. The parametric analysis supplies a vocabulary for being specific about target populations so that performance measurement (and choice of specific data elements) for a given practice is based on their specific aims and not on a measure that is outside their scope.
What is reasonable to expect depending on level of practice development (parameter 5). Some collaborative care implementations may be limited startups or pilots, others are larger scale projects, and a few may be mainstream implementations within a larger organization or community. It would not be appropriate to compare results of limited pilots with mature large-scale projects or mainstream implementations because reasonable performance expectations for these will be different and the specific data elements available may be different. The parametric analysis supplies a three-level classification (pilot, project, mainstream) that allows researchers to choose cohorts of practices that are similar enough in that respect that their results can be meaningfully compared.
A beginning set of internal process measures (based on the 5 paradigm case clauses). While the ultimate goal of collaborative care is improved care and health outcomes, the lexicon (and hence metrics) can also point to internal process measures—evaluation of processes that drive the performance that people ultimately care about. The paradigm case formulation includes five main clauses that describe collaborative care in action. Each clause can become the basis for an internal process measure for practice self-evaluation and quality improvement. Examples are shown in Figure 6 with no attempt to specify actual data elements. Some of the parameters may also be a source of internal process measures. Such measures are important to shape practice performance to the standard that is intrinsically valuable to patients, policymakers, and the public.
Helping Policymakers Form Policies or Payment Models That Support Collaborative Care
Common language for collaborative care in its various forms makes it easier for policymakers to answer these important questions:
- What exactly are people getting from "X" form of collaborative care—what's the product?
- What policies are needed to sustain those functions?
- How much will people pay for that?
- How do I justify that cost as a return on investment?
The lexicon can be used to begin to describe 1) what counts as collaborative care practice, 2) how to distinguish one form of collaborative care practice from another; and 3) what kind of benefit we should expect for whom and on what scale. These are only basic questions, but if the lexicon is used among policymakers and longitudinally over time) it may bring more respectability to the field as seen through policymaker eyes.
Helping Clinicians and Administrators Describe, Compare, and Shape Their Own Practices
The lexicon can serve as a reference for common terms describing required components of collaborative care—and legitimate differences between them. If groups of clinicians talk with each other and those outside the field using the lexicon, they will demonstrate the coherence of their field and their own ability to navigate its language.
Value to clinicians of clarified language. The following excerpt from a personal communication captures potential personal gain in clarified language, especially from the behavioral health side of the collaboration:
...My early frustration was in not knowing what to call myself or how to present myself. Was I health psychology? Behavioral medicine? Behavioral health? Psycho-oncology? Regardless, I knew that to engage the medical establishment, the "field" of psychology needed consistency. I didn't know at the time that the very same issue would continue to plague me over my career. When I began working in primary care, I knew I had to get clear on my language. I was in multiple clinics, with multiple providers, and the only way they were going to keep straight what I offered was [for me and my colleagues] to start using the same language. I knew our field would be stuck without cleaning up our language. We could not even begin to strategize a research agenda without language clarity... whenever I speak to policymakers, I always use the same language. I describe to them the confusion of the field in not knowing what to call itself... pre-empirical clarification is the biggest issue not being addressed for collaborative care...
Value to practices as a structure for self-description or evaluation. The parameters and paradigm case clauses provide a structure that practices can use to ask themselves what they are doing, how well developed or consistent it is in actual practice, and what they are aiming for in their practice. The field has lacked such a shared framework for self-description or self-evaluation, with each practice typically inventing its own. This makes it more difficult for practices to compare and collaborate on practice improvement or create local or regional shared improvement agendas. The field needs a common framework for self-description and self-evaluation if it is to develop as a whole rather than in pockets. The parameters and the paradigm case clauses could be converted to derivative self-description tools ranging from informal, non-scientific "checklists" for organizing observations to a tested scientific instrument with metrics for comparing practices. Early experiments with this are beginning to take place.
Conclusion: The Need for Consistently Understood Concepts and Vocabulary in Emerging Fields
The author has been part of steering groups and planning committees in other emerging healthcare fields, i.e., palliative care, patient-centered medical home, and shared decision-making, that have experienced similar reasons to go through the painstaking process of developing a lexicon, conceptual framework, or operational definition. Through these experiences, it has become apparent that clearer and more consistent concepts and definition for a field are needed when:
- Enough people are stumbling over language and what things mean—especially as encountered in practice, not only in theory or at the level of principles and values.
- Enough people need clearer boundaries for an area X—what counts as, "This is an example of it,"—for describing to the public, setting expectations, assigning insurance benefits and certifications, or saying how something is different than "usual" care.
- People ask, "What components are necessary for a given practice to really be X? What are the dimensions and milestones for practice improvement within these components?"
- Researchers want to ask quality or research questions more consistently and clearly—especially in geographically distributed research or QI networks.
- There is a felt need to improve the consistency or reputation of an area with "outsiders," e.g., policy-shapers, legislators, funders, and others who are not living the experience as "native speakers" of the field.
- Your field is being distorted or misunderstood by the public or a vocal subset, or when practitioners are inconsistent in the way they present the field to the outside world.
Confusion about meanings of terms and conceptual structures appears to be limited not only to the areas described here. The collaborative care lexicon was presented to an audience at the 2010 AHRQ annual meeting—clearly a self-selected, non-random audience of 26 researchers, policymakers, administrators, and clinicians. A non-scientific survey using "clicker" audience response technology asked several questions related to the degree they encounter conceptual confusions in their own work. Even though informal, the results are suggestive of the extent of the problem (Figure 7).
A journey has been underway to articulate and answer empirical collaborative care research questions and help practices achieve the performance that everyone needs them to achieve. The necessary pre-empirical development of a basic conceptual system for this important subfield is being undertaken—something that enables researchers, clinicians, and policymakers to talk to each other using a common vocabulary and an organized way of specifying the required components of collaborative care. The consensus-based collaborative care lexicon described in this paper is an evolving document to be shaped by succeeding groups. A process for involving a larger circle of reviewers is being planned, likely employing members of the Council of AHRQ's National Academy for Integrating Mental Health and Primary Care. This process of involving ever-larger groups of reviewers who broaden and deepen the lexicon (and add their names as contributors) has been used successfully in the previously mentioned projects, e.g., a PCMH operational definition (Peek & Oftedahl, 2010).
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a Corresponding author: C.J. Peek, Ph.D.: firstname.lastname@example.org