What Does Integrated Care Actually Look Like?

A look at one program, and insight into how and why it works

Angela Mattson, DNP, MS, RN
We acknowledge the collaboration of National Network of Depression Centers in developing this series.

There’s been lots of discussion lately about integrated care, and how bringing behavioral healthcare into the primary care setting is the most effective, efficient, and sensitive way to care for people with mental healthcare needs.

But what’s that actually mean? What does integrated (or coordinated or collaborative) care look like from the patient perspective? As the Nursing Supervisor for Care Coordinators in the primary care setting at the Mayo Clinic in Rochester, MN, I’m here to share details on how one collaborative care program works—and how it’s helping people living with depression.

Our team of registered nurses (RNs) partners with patients in the clinic to manage their depression. Since 2008, our collaborative care program has helped patients diagnosed with depression to gain faster access to mental health services within the primary care setting and incorporate self-management strategies to better manage their depressive symptoms and support recovery.

How it works
Primary care patients at Mayo having a history of depression (including patients whose mental health is of concern based on symptoms or comments made during their exam) are asked to complete a PHQ-9 screening tool to assess their reported symptoms of depression. Patients whose PHQ-9 score is 10 or greater and have a diagnosis of major depression or dysthymia are informed about the RN care coordination program and invited to meet with a care coordinator right then in the office. If they are interested in participating, the collaborative journey begins.

The advantage of this instantaneous hand-off is that the RN care coordinator becomes the patient’s primary contact, immediately connecting them to the mental health care they need. This prevents patients from having to initiate or navigate the complex healthcare system themselves and ensures access to care.

After conducting an initial assessment with the patient, the RN care coordinator meets with a supervising psychiatrist to develop an individualized treatment plan. For some patients, the recommendation might be to initiate or adjust anti-depressant medication; others might be referred to a therapist within the practice for cognitive behavioral therapy.

The RN care coordinator will review the supervising psychiatrist’s recommendations with the patient’s primary care provider, who must approve before the care coordinator communicates the plan to the patient. Throughout the process, the RN care coordinator maintains regular communication with the patient—in person, by phone, or via secure messaging every two weeks on average—to discuss symptoms and treatment progress. Utilizing a variety of motivational interviewing strategies, the care coordinators help patients understand the symptoms of depression, feel in control of self-managing their condition, encourage medication adherence or cognitive behavioral therapy as appropriate, and ultimately get to a place where they can discuss their depression just as others may discuss managing diabetes or any other health condition.

Patients may spend up to a year enrolled in our depression care coordination program. Once they score less than five on the PHQ-9 for eight consecutive weeks, they’ve reached remission of their depression symptoms and “graduate” from the program. Having gained knowledge about triggers, warning signs, and ways they can help prevent relapse, patients are referred back to usual care with their primary care team.

Why it’s successful
Our patients most often express appreciation about being able to receive their physical and mental health care from within the primary care clinic. For many, the personalized attention and consistent follow-up made them feel safe and respected, which resulted in them opening up to talk about their symptoms. Some of our patients live with acute and/or chronic suicidal thoughts; RN care coordinators work with them to develop a maintenance and crisis plan for if those thoughts become more intense or severe. There have been occasions where patients felt comfortable in telling RN care coordinators that they were having suicidal thoughts and the care coordinators were able to quickly work with the supervising psychiatrists and primary care providers to assess and address the situations, including arranging for more intensive treatment and services. In such instances, the RN care coordinators helped to save lives.

Admittedly, our providers had some initial hesitation about sharing the care of their patients with someone else. But, with time, they saw how the program better supported their patients within the primary care framework.  Now, knowing how effective it is and seeing the positive impact it has on their patients, providers don’t know what they would do without it.


  • What has been your experience with integrated care?
  • What would improve your experience?

Angela Mattson, DNP, MS, RN, is the Nursing Supervisor for Care Coordination in Employee and Community Health, Mayo Clinic, Rochester, MN. Her responsibilities include working with multidisciplinary stakeholders to assist with the design, implementation, delivery, evaluation, and improvement of care coordination services provided in the primary care setting for medical and mental health patients across the lifespan. She is currently involved in implementation of and research on collaborative care models targeting adult and adolescent depression, anxiety, and substance abuse screening, and care coordination for patients with medical and mental health needs in the primary care setting.

Facebook Comments