Implementing a CDPM program for depression in primary care

Implementing a CDPM program for depression in primary care : The Hamilton FHT Depression Program Nick Kates Program Director, Hamilton Family Health Team Chronic Disease - the Issue  66% of Canadians over the age of 45 have a chronic condition (CC)  55% suffer from two or more chronic condition 80% of primary care visits are for a CC 67% of all hospital admissions are for a CC   The Canadian health system doesn’t do CDM very well – <30% of hypertensives have their blood pressure properly controlled 60% of diabetics have gone >1yr without an eye examination or a check for proteinuria 60% of asthmatics are not properly controlled – – – – 20% of heart failure patients are readmitted <60 days 20% of patients with depression get guideline based care U.S. Institute of Medicine “Between the health care we have and the health care we could (should) have lies not just a gap, but a chasm” US Institute of Medicine, 2001 U.S. Institute of Medicine “Chasm Report” “These quality problems occur typically not because of failure of good will, knowledge, effort or resources directed to health care, but because of fundamental shortcomings in the way care is organized” Thought for the day Systems are perfectly designed to get the results they achieve Chronic Disease Management Better management and outcomes of individuals with chronic diseases requires changes in the ways systems of care are organised Depression is a Chronic and Recurrent Disorder % Recurrence 70 60 50 40 30 20 10 0 0 Keller et al, 1992 .5 1 2 3 4 5 Years Primary Care: Diagnosis and Treatment of Major Depression   Only approximately 50% diagnosed Of those treated, about less than 50% receive guideline-level pharmacotherapy and less than 10% receive guideline-level psychotherapy 45% of individuals stop anti-depresants within 6 weeks (33% don’t tell their family physician) Only 20% of patients seen 3 times within 90 days of starting an antidepressant   Common Medical Illnesses and Depression Major Depression Multi- 23% condition Seniors 15-20% Heart Disease 30-50% Stroke 11-15% Diabetes Psychiatric Illness and Symptoms of Poor Glucose Control     71% of diabetic patients had lifetime histories of one or more psychiatric illnesses Recent psychiatric illness significantly associated with symptoms of poor glucose control 5-10% receive optimal care of their depression Leads to increased morbidity and mortality rates Katon et al Medical Care Dec., 2004 Traditional Organisation and Culture of Care          Focus on acute problems Emphasis on triage and patient flow Short unprepared appointments Follow-up is usually consumer initiated Treat only those people who reach us Can’t identify problems earlier No prevention of episodes / recurrence Brief didactic consumer education Emphasis on provider - not system – behaviour Chronic Disease Management – How to view it  Another planet  Relative test Visionary  Essential Element of Good Chronic Illness Care Informed, Activated Consumer Productive Interactions Prepared Practice Team Chronic Care Model Community Resources and Policies Decision Support Health System Health Care Organization SelfManagement Support Delivery System Design Clinical Information Systems Informed, Activated Consumer Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Ontario’s CDPM Framework INDIVIDUALS AND FAMILIES Healthy Public Policy Personal Skills & SelfManagement Support Delivery System Design Supportive Environments Community Action HEALTH CARE ORGANIZATIONS Provider Decision Support Information Systems Productive interactions and relationships Activated communities & prepared, proactive community partners Informed, activated individuals & families Prepared, proactive practice teams Improved clinical, functional and population health outcomes The “Kaiser Triangle” Population Management: More than Care & Case Management Level 3 Highly complex members Intensive or Case Management Assisted Care or Care Management Level 2 High risk members Usual Care with Support Level 1 70-80% of a CCM pop Self-Management Support  New partnership between providers and consumers   Next revolution in health care Only beginning to understand what it means for a consumer to be a partner in care Most consumer education to date is ineffective  Self-Management Behaviour change does not necessarily result in changes in health status Feelings of being more in control of the illness Self Efficacy Self-Management - options         Patient goals Consumer plans Relapse prevention plans Healthy lifestyle Copies of records Education Health passport Groups Completely consistent with a recovery approach Evidence from the literature re CDPM for depression BreakThrough Series reviews: What works –successful depression projects  Depression has best outcomes of all CDM programs – – Patient registry Care co-ordination – – Proactive follow-up Psychiatric consultation / Diagnostic assessment BreakThrough Series reviews: What doesn’t work    Education not effective on its own Guidelines not effective on their own Screening not effective unless linked to follow-up  Feedback no benefit on its own Hamilton FHT (HSO) Mental Health (and Nutrition) Program  1994  1996  2000 MH Program started – 45 physicians Expansion – 41 new physicians Took over administration of nutrition program – Became part of Hamilton Family Health Team  2005 HSO Mental Health and Nutrition Program - 2006  80 practices sites family physicians  105  145  340,000 patients (68%) Integrating Mental Health Services within Primary Care Ratio Clinicians   FTEs 1996 22.9 2.2 FTEs 2006 50.5 4.8 Counsellors Psychiatrists Programs 1:7,200 1:75,000 Central Program Original goals of the program 1. To increase accessibility to mental health care for primary care patients 2. To expand the range of mental health services delivered in primary care 3. To strengthen linkages between primary care and mental health/community programs. 4. To increase family physicians’ skills and comfort in handling mental health problems. Outcome measures CES-D 40 35 30 25 20 15 10 5 0 Before After All changes significant p<.05   Mean change Improved > 1 SD 21.2 68% Before After  Score reduced > 50% 79% Outcome measures SF-8 50 45 40 35 30 25 20 15 10 5 0 Before After  Mean change Improved > 1 SD 17.8 62%  Before After  Score reduced > 50% 68% All changes significant p<.05 Co-location is not enough CHANGING THE PARADIGM      Focus on populations Focus on longitudinal care / closing the loop (a system of care) Requires teams Identified care co-ordinator Patients as partners IT support  Chronic Disease Management Better management and outcomes of individuals with chronic diseases requires changes in the ways systems of care are organised Introducing CDPM CHANGING THE PARADIGM  Not a model A way of conceptualising care A framework for re-organising care Applicable to any system    2nd. Thought for the day How can I re-design my system to get better results What we already had      Role of counsellor as case / care co-ordinator Stepped model of care Specialist providing evidence-based advice Teams in many primary care practices Limited self-management support What we already had        No registries / ability to monitor No population focus Not standardised treatments Use of specialists for decision support Links with community resources (program not practice) Program management team Created a “bottom-up” model CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT Screening / Detection Provider preparation Screening Instruments Assessment Tools Patient Information Practice review Treatment Algorithm Case Management System navigation Specialist Consultation Prepared Appointment Follow up / Monitoring Telephone Registry Routine recall Reminders Self Management Goals Plan / relapse prevention Access to Records Education Provision of resources / aids Health Passport Groups Information Systems Decision Support Flow sheets Provider education Templates Website Specialist Access Targets Organizational Change Goals Team creation Evaluation EMR Provider Training Change Manageme nt Coordinating Care Community Links Key Partners Agencies in primary care Links with agencies Community Action Building healthy policy Supportive environments CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT Screening / Detection Treatment Follow up / Monitoring Self Management Information Systems Decision Support Organizational Change Community Links Community Action Provider preparation Algorithm Telephone Goals Flow sheets Provider education Goals Key Partners Building healthy policy Screening Assessment Patient Instruments Tools Information Practice review Case System Specialist Prepared Management navigation Consultation Appointment Registry Routine recall Reminders Education Provision of Health resources / Passport aids Groups Plan / relapse Access to prevention Records Templates Specialist Access Team creation Agencies in primary care Supportive environments Website Targets Evaluation Links with agencies EMR Provider Training Change CoManage ordinating ment Care CDPM / PROGRAM PLANNING GRID FOR THE HAMILTON FHT Screening / Detection Treatment Follow up / Monitoring Self Management Information Systems Decision Support Organizationa l Change Community Links Community Action Provider preparation Algorithm Telephone Goals Flow sheets Provider education Goals Key Partners Building healthy policy Screening Assessment Patient Instruments Tools Information Practice review Case System Specialist Prepared Management navigation Consultation Appointment Registry Routine recall Reminders Education Provision of Health resources / Passport aids Groups Plan / relapse Access to prevention Records Templates Specialist Access Team creation Agencies in primary care Supportive environments Website Targets Evaluation Links with agencies EMR Provider Training Change CoManage ordinating ment Care PDSA cycles – Plan Do Study Act PDSA cycles – Plan Do Study Act Not everything will work out exactly as anticipated Detection  2 Screening questions for family physicians  If indicated, follow-up with PHQ-9 Include all patients with a chronic illness  www.depression-primarycare.org/clinicians/toolkits/ www.nice.org.uk/CG023 Treatment by Family Physician  Initiation of an antidepressant – See monthly for 3 months – Follow existing treatment protocols re dose / duration – Discuss with psychiatrist if any questions / issues arise – Use PHQ-9 to monitor Supportive psychotherapy Self-management support / lifestyle counselling   Referral  To counsellor – – ? Criteria ? Reason for referral  To psychiatrist – – – – – – For discussion or consultation Non response to 2 antidepressants Diagnostic question Other related issues (ie insurance claim) 1-2 visits Discuss  (To exercise specialist / registered dietitian / peer) Treatment by Counsellor         Assessment ? CBT or IPT ? Time-limited ? When to involve psychiatrist Involve significant others Care manager / co-ordinator Pursue patients who don’t show Follow-up phone call at 3, 6, 12 and 18 months - scripted Incorporate self-management support   Help each patient develop their own goals Develop a plan   Give patient a copy of the plan List of medications and written instructions if necessary   Give patient a copy of reports / relevant notes Educational materials – printed / web sites INTERACTIVE Co-ordination of care – In a Practice  Development of a registry – – – – – Initially prospectively Paper or Excel Build in medication Build in follow-up calls Build in other care components    Identify who will oversee registry development / follow-up Identify who will call re follow-up Prepared visit – morning huddle Preparation of practices / providers Involve practices in planning from the outset  Frequent meetings / visits   Facilitator    Lunchtime meetings - ? Offsite Preparatory session for counsellors / psychiatrists Follow-up sessions at 6 months Introducing the model  Not everything at once – develop a hierarchy of changes Start with pilots PDSA     Keep guidelines / protocols as simple as possible Each practice will adapt to its own situation Challenges  Providers adjusting to a new model – – Family physicians Mental health counsellors      Functioning v. symptom severity Addressing co-mprbid problems Counsellors see more than just depression Criteria for referral Logistics