Self-Management _ Care Management in the Treatment of Depression

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					      Self-Management &
       Care Management
in the Treatment of Depression

          Neil Korsen, MD MSc
           Amy Quatticci, RN
                PRISM #4
            January 17, 2008
          Improving Depression Care:
                Five Key Components
1.   PHQ-9, an outcome measure for depression (for more information
     see eLearn Module 1: Using the PHQ-9 for Diagnosis and Management of
2.   Use of a registry such as the Clinical Improvement Registry
3.   Self-management Support
4.   Care management
5.   Informal psychiatric consultation
  Overview of this module
I. Self-management support (SMS):
   What it is and how to use it
   Recognition and prevention of relapse and recurrence of
II. A team approach to SMS:
   An effective way to implement self-management
III. Care Management:
   An important role in SMS
I. Self-Management Support
          Components include:
1. Education of patient and family/friends
   about depression
2. Patient self-management with goal setting and
   action planning
3. Connecting patient with useful community
  Self-Management Support
 What is it?
   – The information, education, resources, and care offered to
     people with chronic conditions to help them deal with their
     illness. The goal of self-management support is to strengthen
     people’s competence and confidence to manage their
     condition, make informed decisions about care, and adopt
     healthy behaviors.     
 Emphasizes:
   –   Reasonable problem solving
   –   Realistic goal setting and action planning
   –   Relapse prevention
   –   Shared decision making
  Goal Setting and Action Planning
 Have the patient focus on what they want to do or what
  they enjoyed doing prior to depression.
 Ask them to set a goal based on something they want to do
  or used to enjoy.
   – Sample goal: Increase physical activity.
 Action plans involve the small steps needed to reach a goal.
   – Sample action plan: Walk around the block at 9 AM on
     Monday, Wednesday and Friday each week.
  Action Planning: Tools
  All tools are available at in “For Healthcare
       Professionals” and “Health Information” in “Depression.”
 My Self-Care Plan can be accessed:
    – From the menu on the left of this eLearn module.
    – By clicking on the link:
    – Copies can be ordered online from JS McCarthy:
 Can also be written on a prescription pad or simply on a piece of
Why action plans rather than goals?
 Goals are generally too big for patients to work on all at
  once (e.g., lose 30 lb, quit smoking).
 Goals can be overwhelming and often fail due to lack of
  planning the small steps towards the bigger goal.
 When patients do not succeed in reaching their goal they
  may lose motivation.
 Action planning helps patients break down goals into more
  doable steps.
Action Planning: Confidence Level
 Once an action plan is set, have the patient indicate
  how confident they are that they can achieve it (1-
  10 scale).
 If the confidence level is <7, discuss with the
  patient how they might modify the plan to reach a
  confidence level between 7 and 10.
 Action plans should be written and a copy given to
  the patient.
Action Planning: Keys to Success

 It is crucial to have success at the beginning.
 Successful action plans are specific:
   – “I will walk for 15 minutes in the morning on Mondays,
     Wednesdays and Fridays”, not “I will exercise more”.
 A confidence level 7 or greater on the action plan is
  associated with better success.
What can I do to help my patients succeed?
  Give patients a copy of their action plan and keep one for
   the medical record.
  Follow-up is key:
    – Initial follow-up should occur by phone or in person in 1 to 3
      weeks. This can be arranged at the initial visit or contact can be
      made by a care manager or medical assistant in that time frame.
    – Adjustments can then be made toward a larger goal or keep
      tweaking the action plan until successful.
    – Reinforce the positive by focusing on any success, even partial
      completion of goals.
Relapse & Recurrence
  Symptoms of depression can worsen (relapse)
   during treatment
  At least half of all people who have major
   depression will have at least one more episode
   (recurrence) after some period of being symptom-
  Part of self-management support for depression is
   preparing people to recognize and react to relapse
   or recurrence
  Relapse Prevention
 Relapse prevention involves helping people with depression
  identify triggers to depression and early symptoms that might
  serve as a warning to relapse or recurrence.
 The Depression Action Plan is a tool to support developing
  a plan with the patient about how to recognize and manage
  new symptoms once they’ve achieved response or remission.
 You can access the depression Action Plan from the menu on
  the left of this eLearn Module and at:
Education and Community Resources:
  It is important to provide information to people with depression
   and their families, and to help them connect with community
   organizations that can provide additional information and support.
  Brochures, posters and copies of the PHQ-9 in the office can start
   the education process.
  Patient handouts are available on the MaineHealth website:
    – Follow “For Healthcare Professionals” then to link to “Depression”
  MaineHealth Learning Resource Centers:
    – Located in Falmouth, Portland and Scarborough
    – Offer written materials, videos and Living Well With Chronic Conditions
  Consumer Organizations
 National Alliance on Mental Illness (NAMI)
   –11 local chapters in Maine;
 Depression Bipolar Support Alliance (DBSA)
   –5 local chapters in Maine;

   Both organizations provide support and education for
      people with mental health problems and their
II. A Team Approach to Self-
     Management Support
Organizing your practice team for SMS
 The clinician needs to support the value of SMS, but can
  delegate some roles to the team.
 Office staff can be trained to provide self-management support
  to patients.
 Members of the team may include the nurse, medical assistant
  (MA) and care manager.
 The team can develop workflows to make sure that self-
  management support is integrated into care.
Some Examples of Team Approach
 MA gives patient a copy of self-care action plan as
  part of rooming process and reviews with patient.
 Clinician encourages goal setting, and MA or care
  manager follow up to help patient with action
 Care manager calls patient 1-2 weeks after office
  visit to follow up on action plan.
III. Depression Care Management
 What is depression care management?
 An evidence-based component of depression care,
  shown in multiple clinical trials to improve outcomes
  for people with depression.
 Designed to improve and facilitate patient follow-up,
  support patient self-management, and provide the
  linkage of patients and community resources.
Key Functions of Care Management
 Assess and facilitate adherence to treatment
  including medications, counseling and follow-up
  appointments with PCP.
 Support self-management activities.
 Provide guidance, not psychotherapy.
 Assess and monitor treatment response.
 Provide a key communication link between the
  patient and the practice.
Why use Care Management for depression?

 CM is proven to help decrease patients’ symptoms of
 Evidence of increased adherence to treatment.
 CM is cost-effective.
 Helps PCPs overcome the barrier of lack of time:
   – To set goals and develop action plans
   – To provide patient education
Evidence for the Value of Care Management

  Simon et al, BMJ 2000
    – Population – 613 people starting treatment for depression.
    – Results – Intervention group more than twice as likely to
      have improvement in symptoms.
  Katzelnick et al, Arch Fam Med, 2000
    – Population – 407 high utilizers of services in an HMO
    – Results – Intervention group had greater improvement in
      Hamilton Depression scores at 3, 6, and 12 months.
Evidence for the Value of Care Management
  Hunkeler et al, Arch Fam Med 2000
    – Population – 302 people in an HMO starting antidepressant
    – Results – Intervention group had greater improvement in
      Hamilton Depression scale at 6 weeks and 6 months
  Unutzer et al, JAMA 2002
    – Population – 1801 people aged 60 or older with depression.
    – Results – At 12 months of follow-up, intervention group
      was 3.5 times more likely to have improvement in
        • Intervention group also reported improved quality of life.
Evidence for the Value of Care Management
    Dietrich et al, BMJ 2004
     – Population – 405 adults starting or changing treatment
        for depression
     – Results – Intervention group had an increased rate of
        clinical improvement at 6 months
     – Note: MaineHealth practices were part of this study
    Which patients with depression should
     be referred for Care Management?
   Patients scoring 15 or higher on the PHQ-9 are the group for
    whom there is the most evidence of the value of care management
    for improving outcomes.
   Others who might also benefit from Care Management include:
      – Patients scoring lower than 15 who choose watchful waiting
          as their treatment (see next slide for description of watchful
      – Patients who lack adequate family or social support.
      – Patients who need help affording medications or with referrals
          to mental health specialists.
  What is Watchful Waiting?
 It is estimated that a third of people with mild symptoms
  (PHQ score less than 15) will recover without treatment.
 Watchful waiting means you are seeing the patient about
  once a month and monitoring their PHQ-9 score, but not
  starting active treatment.
 Self-management activities, such as exercise, socialization or
  relaxation, are usually a component of watchful waiting.
 If the patient’s symptoms have not resolved after 2-3
  months, active treatment ought to be considered.
      Care Management Process
      (applies to MMC PHO members)
1. PCP refers patient to care manager.
2. Care manager initiates contact with patient
   via phone.
3. Care manager provides feedback to PCP.
Care Management for depression
 Recommended Call Schedule
   Week 1
   Week 4
   Week 8
   Week 12
   Week 16
   Other calls as needed
   Calls after week 16 determined by patient remission
    status and risk
 Initial & Follow-up Calls
 Care manager (CM) engages the patient.
 CM explains role and connection to PCP.
 CM answers questions and provides information.
 CM may repeat the PHQ-9 by phone to assess
  response to treatment.
 CM communicates initial and follow-up call outcomes
  to PCP.
      Care Manager’s Role in SMS
 Helps patient identify a self-management goal if not
  previously identified by PCP
 Encourages small steps by helping patient develop an
  action plan
 Assesses confidence level
 Provides positive reinforcement
 Monitors progress
 Modifies or helps set new goals as needed
 Helps patient find and access appropriate local programs,
  e.g., Living Well with Chronic Conditions course
    Advantages of Care Management &
 Added resources to help patients and families
  understand depression and its treatment.
 Maintains link between patient and practice during the
  acute phase of treatment, therefore fewer patients lost
  to follow-up.
 Improved outcomes for patients initiating
  antidepressant therapy.
 Self-management support is an important
  component of care for people with depression.
 Collaborative goal setting and action planning
  is more effective at promoting behavior change
  than traditional clinician-directed advice.
 Care management is an effective tool for
  improving depression treatment in primary care