Can Coordinated Care Improve Outcomes?

David Katzelnick, M.D.
Chair, Division of Integrated Behavioral Health
Mayo Clinic Rochester Minnesota
We acknowledge the collaboration of National Network of Depression Centers in developing this series.

Mental health and physical care coordination is an idea whose time has come. Not only is it proven to provide better patient outcomes, it achieves success at significantly lower costs.

Both TEAMcare, utilized throughout North America, and Care of Mental, Physical, and Substance-use Syndromes (COMPASS) are receiving growing acceptance and success. COMPASS is based on several successful, team-based, primary care setting models such as IMPACT and DIAMOND. Like those earlier programs, COMPASS depends upon a multidisciplinary care team.

At the hub is the care manager (typically a RN), who is specially trained to work with patients with both mental and physical conditions. Once a patient is identified for COMPASS (based on the presence of diabetes and/or heart disease with co-occurring depression and possibly risky substance use), the care manager steps in to support the primary care team.

Working under the direction of the primary care provider, the care manager coordinates the patient’s care, provides education, and supports self-management for the target conditions. Additionally, the care manager regularly monitors symptoms, lab results, and adherence to treatment.

A consulting psychiatrist (for depression) and a consulting primary care specialist (for diabetes and/or cardiovascular disease) routinely review all COMPASS-enrolled patients with the care manager. During periodic reviews, the team discusses all new patients, as well as those not responding to treatment, to determine if changes to patient care plans are needed. Coming out of this consultation, the care manager conveys any recommended treatment changes to the primary care physician.

Patient-centered care
Whether provided by COMPASS, TEAMcare, or other models, integrated care works because it is based on putting the patient’s needs first. And for the patient this often means receiving treatment in a timely manner. Because the COMPASS program relies on the care coordinator to serve as a patient advocate, treating physicians are able assess and treat many more patients than in a traditional medical model. Unlike the traditional model where a patient receives a referral, schedules an appointment, and then waits for the appointment date to arrive, I can review as many as 150 patient profiles a day. Together, with the entire care team, we assess who is progressing with treatment under supervision of the care coordinator and who might require more intensive care for to treat their mental health condition.

Primary care providers embrace coordinated care because they are working in close concert with a qualified mental health provider. They are no longer solely responsible for patient education, self-management, and symptom and side-effect tracking, allowing them to focus on the areas of patient health management they are professionally trained to deliver.

Because COMPASS includes ongoing tracking and follow-up, patients’ progress is monitored and quick intervention can be initiated for those who are not improving. In some cases, a face-to-face consultation with the consulting psychiatrist is arranged and treatment is adjusted based on that evaluation. This results in better allocation of resources, as only patients who truly require higher-level resources receive them.

The future of mental health care
Five to ten years ago, when we first proposed team-based models, nobody knew what we were talking about. Now, this idea is being effectively implemented by some of the most well-respected institutions in the country and has a rich body of evidence to support it.

COMPASS may not be achievable everywhere. Many primary care settings do not have staff to provide care coordinator services and some communities lack mental health professionals to provide consulting psychiatric services. But the philosophy behind COMPASS — that we must treat the whole patient and coordinate treatment for mental and physical health conditions — is one that can be adopted anywhere.

Advocate for coordinated care
As a patient or loved one of someone living with a mental health condition, you can encourage primary care providers to think about mental health care in a more comprehensive and integrated manner.

  • Ask your primary care provider which mental health providers work with the clinic. If they have no relationships with mental health providers that might be a warning sign that mental health is not given adequate attention in the practice.
  • Ask, “If I have depression, what would you do?” If the answer is a referral to a generic 800 number, you may want to think about finding a new practice.
  • Advocate for your state Medicaid director to apply for an Excellence in Mental Health Act planning grant. One of the requirements of this program is care coordination across settings and providers, addressing the full spectrum of health services in partnership with federally-qualified health centers.


  • What has been your experience with coordinated care?
  • What would improve your experience in treating physical and mental health conditions simultaneously?
  • What discussions have you had with your mental and physical health providers regarding care of you as a whole person?


David J. Katzelnick, M.D., is the chair of the Division of Integrated Behavioral Health at the Mayo Clinic Rochester Minnesota and a member of the Executive Board of the National Network of Depression Centers (NNDC).His major clinical and research interests are in mood and anxiety disorders, psychopharmacology, diagnosis and treatment of mental disorders in primary care, and medication education. He is currently Mayo Co-PI for the COMPASS Centers for Medicare and Medicaid services (CMS) grant, which has the goal of spreading a collaborative care management model to manage patients with depressionand diabetes and/or cardiovascular disease.

Disclaimer: The project described was supported by Grant Number 1C1CMS331048-01-00 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

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