A National Agenda for Research in Collaborative Care
Charlotte Mullican, M.P.H.
At the AHRQ-funded Collaborative Care Research Network Research Development Conference in Denver in October 2009, key national leaders took major steps toward establishing a research agenda for collaborative care among primary care and mental health clinicians. This set of three research papers represents the fruits of that meeting. The papers support and advance AHRQ's portfolio of primary care research.
The Collaborative Care Research Network (CCRN), which convened the conference, is a sub-network of the American Academy of Family Physicians National Research Network. CCRN was created so that clinicians from across the country can investigate how to make collaborative care work more effectively. CCRN is one of the practice-based research networks of primary care clinicians and practices that work together to answer community-based health care questions and translate research findings into practice.
The authors (Miller, Kessler, and Peek) supplied the following orientation to these papers.
The papers describe the creation of a research agenda for collaborative care. This emerging field emphasizes the recognition and care of mental health problems in primary care settings and the effective collaboration of primary care and mental health clinicians. Collaborative care is regarded as an important function of the patient-centered medical home (PCMH), and one avenue toward achieving PCMH goals for health, patient experience, and affordability. More research is needed to identify which particular functions or components of mental health and primary care integration lead to improved outcomes and add value in the PCMH. Such research will have clinical, system design, and policy implications.
This overview is intended to familiarize the reader with the interconnected purposes and concepts in the three papers and how to navigate them as a set.
Establishing a Research Agenda for Collaborative Care (Miller, Kessler, and Peek). This paper presents the research agenda, identifying two sets of questions that need investigation in collaborative care. Part A questions describe the models and functions currently being employed in the field of collaborative care. Part B questions are evaluative. What collaborative care functions or models currently in use lead to improved outcomes and for whom? This is a research agenda to find out what makes or does not make a positive difference among the many variants of collaborative care seen in practice. The agenda is meant to be an ongoing process of mapping existing practice across the country and discovering which forms of it make a positive difference to whom.
In addition to the research agenda, the paper describes gaps in the literature, how the Research Development Conference was used to create the research agenda, and how it became necessary along the way to develop a lexicon for the common terms and components for collaborative care so that research questions can be framed in a consistently understood manner.
A Framework for Collaborative Care Metrics (Kessler and Miller). This paper serves as a researcher's tool for providing metrics (data elements) needed to carry out the research questions identified in "Establishing a Research Agenda for Collaborative Care." It proposes specific metrics for the degree that the necessary functions of collaborative care cited in the collaborative care lexicon (see below) and the research agenda are working in a given practice. It is one thing to have a lexicon or conceptual structure for asking consistently understood practice development and research questions—and another thing to have measurable indices (metrics) on hand that can serve as quantitative measures or approximations of otherwise qualitative descriptions of collaborative care practice that are contained in the lexicon and the research agenda.
The paper briefly reiterates the problems of providing mental health services to individuals in medical settings, the gaps in the effectiveness literature for collaborative care, and the importance of a consensual lexicon that provides consistently understood definitions for collaborative care functions and metrics derived from it.
A Collaborative Care Lexicon for Asking Practice and Research Development Questions (Peek). This paper can be considered the narrative "back story" of why and how the collaborative care lexicon was developed for AHRQ's research development conference. It reviews the difficulty of articulating consistently understood research questions (or even planning the conference) because of differences in language and concepts of what the components of collaborative care are and what they should be called. The paper reminds us that examples of definitional or lexical confusion are common in the history of science and that collaborative care is an emerging field that like others has had to refine its pre-empirical conceptual/definitional system prior to doing good science.
The method for creating this collaborative care lexicon for the conference is described, along with the lexicon itself; the benefits to clinicians, patients, policymakers, and researchers; and the budding applications in other emerging fields of healthcare such as palliative care, patient-centered medical home, and shared decisionmaking.
Figure 1: Interrelated purposes and content of the three papers
From Lexicon Definitions to Practical Metrics: the Flow of Concepts in the Papers
Orienting the reader to the purpose of each paper and how they connect is easy. What is more challenging (and more important) is to prepare the reader for the flow of concepts from one paper to the next. In particular the reader should be prepared to see how research questions framed with terms from the lexicon end up becoming metrics that are also derived from that same lexicon. The collaborative care lexicon contributes to language for the research questions and for the elements to be measured and the specific metrics as shown partially below. We hope the reader finds the journey through these papers interesting and energizing—perhaps enough to participate in the research itself.