Predictors of Sustainability in the Collaborative Care Medicaid Program for Depression: A Cross-Sectional Study

OBJECTIVE: This study aimed to determine predictors of long-term collaborative care reach and effectiveness. METHODS: The authors conducted a cross-sectional observational study of the New York State Collaborative Care Medicaid Program (CCMP). Subjects included clinics participating in CCMP from 2012 to 2019 with a ≥0.5 full-time-equivalent (FTE) care manager and data from 2021, 2022, or both. Main measures included clinic and fidelity characteristics. Outcomes were reach and effectiveness. Multilevel negative binomial regression models were used, with analyses adjusting for clustering by health care system and county. RESULTS: Of 157 eligible clinics, 71% were Federally Qualified Health Centers (FQHCs); the median caseload per care manager FTE was 55; reach, 13%; and effectiveness, 42%. In multivariable analyses, CCMP factors associated with reach included more engagement (adjusted rate ratio [aRR]=1.15), higher care manager FTE (aRR=1.06), larger caseload per care manager FTE (aRR=1.23), smaller clinic size (aRR=0.60), earlier adoption (aRR=0.40 in 2017-2019 vs. 2012-2014), and fewer academic or private clinics (vs. FQHCs) (aRR=0.66). Higher caseload per care manager FTE (aRR=1.05), more psychiatric consultations (aRR=1.04), greater early implementation effectiveness (aRR=1.07), and more FQHCs (aRR=1.15) were associated with greater effectiveness. CONCLUSIONS: Despite ongoing fiscal and technical assistance strategies, the CCMP struggles to achieve long-term reach. This study provides potential targets for optimizing implementation settings and pace of sustainability and is among the first to suggest a reciprocal relationship between effectiveness and reach and that an optimal caseload may promote both.