Implementation of Digital Mental Health Tools in Ambulatory Care Coordination

Project: Research project

Project Details


Care coordination services have been developed to provide safer and more effective care for patients who have difficulty managing their healthcare. The role of care managers (CMs) working in care coordination is intended to take a holistic view of patients and to improve healthcare system efficiency, yet there remain several gaps in the efficiency of this work. CMs often struggle to find resources for their patients, particularly in the realm of depression management. Resources are limited, waitlists for services are long, and many patients are hesitant to seek mental health care. Our research group has developed a productive partnership with the Ambulatory Care Coordination service at Northwestern Medicine – a large integrated delivery system of more than 3,500 physicians, serving 1 million patients. Currently CMs, primarily nurses by training, provide remote coordination services to patients who typically have multiple physical and mental health conditions. They report abundant challenges in supporting patients with depression. A digital mental health intervention packaged within a patient management system for depression would fill the need for depression management resources and fit into CM work. The overarching aim of the proposed project is to adapt and implement a digital mental health intervention to improve access to and coordination of mental health services in Ambulatory Care Coordination. Specifically, this study aims to: 1) adapt a digital mental health platform and service model to address implementation barriers within care coordination, 2) develop and subsequently optimize a multicomponent implementation strategy, and 3) conduct a randomized rollout effectiveness-implementation trial of the digital mental health platform and a sustainment pilot period in the 4 regional teams of the Ambulatory Care Coordination service. Data gathered throughout this project will be used to develop an implementation guide, capable of being used by other for healthcare systems as they expand their mental health service offerings to provide holistic support for patients.
Effective start/end date9/1/216/30/26


  • Agency for Healthcare Research and Quality (5R01HS028003-03)


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