Re-Engineering Systems for the Primary Care Treatment of Depression
Allen J Dietrich, MD
Dartmouth Medical School
John D. and Catherine T. MacArthur Foundation
Additional Authors
John W Williams Jr, Thomas E Oxman, Herbert C Schulberg, Martha L Bruce, Pamela W Lee, Kurt Kroenke, Martha S Gerrity, Paul A Nutting, Kathryn M Rost, Sheila Barry, Patrick J Raue, Jean J Lefever, Moonseong Heo
Background
Primary care is a natural point of entry to depression recognition and management Effective, sustainable models of depression management are available, but present challenges to implement
Recent Depression Advances
USPSTF endorsement for screening Systematic follow-up and monitoring
Severity measure (PHQ-9)
Telephone support (care management) Collaboration with mental health
Research Goal
To test the effectiveness, sustainability and dissemination potential of an evidencebased clinical model and dissemination approach designed to improve the quality of depression care.
Project Phases
Phase
One
Design
Pilot test
Scope
10 practices
Evaluation
Feasibility Modifications
Two
Three Four
RCT
Sustainability Dissemination
60 practices
30 Practices ≥ 100 practices
Process Outcomes
Continued Use Fidelity Adaptations Quality Indicators
RCT Study Methods
Design: Practice level, randomized trial
Setting: 5 health care organizations and 60 primary care practices
Intervention: Three Component Model (TCM)
PRIMARY CARE CLINICIAN
CARE MANAGER
PATIENT
MENTAL HEALTH SPECIALIST
Clinical Roles
Primary Care
Diagnosis, treatment(s)
Care Manager
Telephone support: adherence, self-management, treatment response, physician feedback Care Manager supervision, informal advice
Mental Health
Planned Patient Contacts
Primary Care PCC Clinician Visit Acute Phase PCC PCC PCC PCC
Care Manager CM Phone Call
Continuation Phase PCC PCC
CM
CM
CM
CM
CM
1 2-3
4 6
8
12 16 WEEK
24
32
36
Practice Characteristics
Characteristic Clinicians (mean) On-site mental health Internal Medicine TCM 3.8 ± 3.4 22.6% 34.4% Usual Care 3.7 ± 2.7 29.6% 31.1%
Patient Characteristics
Characteristic Age (mean) Female Ethnic minority GAD TCM 41.8 ± 14.1 83.5% 16.1% 41.7% Usual Care 42.2 ± 15.3 76.2% 17.9% 40.0%
Panic Disorder
22.9%
17.7%
Physician Actions
100%
* * *
e cid i e f re P e nc e er als o
Completed Action
80% 60% 40% 20% 0%
Su
t ca du E
TCM
SM
G
Usual Care
*P < 0.01
Telephone Follow-up
100% 80%
P=<.0001 P=<.0001
Any calls
60% 40% 20% 0% 0-3 Months TCM Usual Care 4-6 Months
Adequate Dose Antidepressant
80%
*
Current Use
60% 40% 20% 0% 3 Months TCM Usual Care
*P < 0.01
6
Depression Response
100%
> 50% Symptom Reduction
80%
P = .02
P = .001
60% 40% 20% 0% 3 Months TCM 6 Months Usual Care
Quality Of Depression Care
100%
P=.008 P<.001
Excellent/Very good
80% 60% 40% 20% 0% 3 Months TCM Usual Care 6
Summary
Modest evidence-based enhancements can:
Improve care process Improve patient outcomes
Why does it work?
More patient contact Suicide assessment, educational materials, self management, telephone support, PHQ-9
More with adequate medication dose.
Challenges and Solutions
Lack of reimbursement Competing priorities Re-invention
Challenge One
No central care manager Potential solutions:
Train an office staff person to do follow up calls Be highly selective in patients called Provide supervision for that staff person within the practice
Challenge Two
Some patients not covered by plan (Mass Health) Potential solution:
Pro-active screening by plan
Challenge Three
Adequate dose Potential solutions:
PHQ-9 discipline Upfront education to patient Audit/feedback
Challenge Four
Tracking Patients Potential solutions:
Initial call Flexible hours Refer problems back to PCC
Challenge Five
Self management for difficult to engage Potential solutions:
Care manager support Scheduled social time Planned enjoyable activities
Challenge Six
Comorbid psychosocial conditions Potential solutions:
Develop integrated system that addresses common comorbid conditions Exclude highly complex comorbidities
Conclusions
TCM provides a framework Tools, teamwork, tenacity Routines and re-invention
http://www.depression-primarycare.org/