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Effectiveness, Feasibility, and acceptance of care management for depression in patients and clinicians.

Rationale / Objectives

Depression is a common condition in primary care practice, with a prevalence of 5% to 9% of patients. Most patients first seek attention for their symptoms in primary care, rather than in the mental health specialty sector. Since primary care visits are necessarily brief and pressured by competing demands to manage other medical problems, there was a substantial deficit in the adequacy of care.

Practice system changes, including care management, were necessary to improve depression outcomes. This qualitative study examines barriers and benefits to adopting depression care management among 42 primary care clinicians in 30 practices and provides evidence for the effectiveness of programs to improve primary care of depression, based on the chronic care model. 1 4

Project/Program Description & Major Achievements

  • The research team for Re- Engineering Systems for Primary Care Treatment of Depression (RESPECT-D) conducted an extensive qualitative investigation into the factors contributing to successful implementation and dissemination in adopting depression care management among 42 primary care clinicians in 30 practices.
  • The team also identified barriers to its adoption. They implemented the Three Component Model (TCM) for improving depression care. TCM is characterized by Care management, Enhanced mental health support and prepared practice. Two main partners in implementing TCM are care manager and mental health specialist.
  • RESPECT-D implementation of TCM doubled the odds of achieving 50% reduction in depression symptoms as well as remission at 3 to 6 months. Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. 1 2 3 5

 

Lessons Learned

  • Lack of reimbursement for primary care management of depression and adding a care manager to the primary care team were often cited as economic barriers.
  • Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Physicians felt burdened by the time spent in communication with care managers, or attending to care management form-filling and found changing the practice very difficult and did not merit the effort unless making a significant difference.
  • Most physicians were reluctant to link services to a health plan, providing improved care to only those patients with the proper coverage. 1 2 3 5

Further Description

This qualitative study examined the barriers and benefits to adopting depression care management through five community-based health care organization (HCO) including 42 primary care clinicians in 30 practices and provided strong evidence for the effectiveness of programs to improve the primary care of depression based on the chronic care model.  Re- Engineering Systems for Primary Care Treatment of Depression (RESPECT-D) was designed not just to test an integration model, but also the ability of a model to be disseminated across organizations 2. The RESPECT-Depression project enrolled 224 patients who were known to struggle with depression by their primary care clinicians and who agreed to participate in a care management program. Each received a telephone call from a practice- or centrally-based care manager 1, 4, and 8 weeks after the initial visit, and every 4 weeks thereafter until depression remission. Telephone calls averaged 10 minutes and served to identify and address barriers to treatment adherence and to measure response to treatment using the Patient Health Questionnaire PHQ-9. The clinicians received reports about patients’ progress, including the PHQ-9 scores and care managers’ action taken. Care managers regularly discussed their patient contacts with a mental health professional from their HCO. Based on the information discussed, the mental health professionals provided feedback to the clinicians with suggestions about management. For more complex issues the mental health professional and primary care clinician spoke by phone. Clinicians received brief training on guideline-concordant depression care, but they followed their own clinical judgment in care for the patients enrolled in the project. Most of the participating clinicians were family physicians, with only a few general internists, nurse-practitioners, and physician’s assistants. RESPECT-D included a follow-up phase during which the health care organizations which had participated in the trial were provided training and instrumental support, including grant money, to implement a plan to disseminate the integrated model across the organization.3 4

Major Achievements

RESPECT-D implementation of TCM doubled the odds of achieving 50% reduction in depression symptoms as well as remission at 3 to 6 month.  Most of the clinicians believed that the care manager improved their care of depression and endorsed the value of care management for their patients. In two of the organizations all 29 participating practices continued the TCM, while all 31 practices from the other three organizations did not because of Lack of reimbursement for primary care management of depression and Physicians felt burdened by the time spent in communication with care managers. 3 6

Metric Result Detail
Depression symptoms Reduced by 50% Among RESPECT-D project patients
Remission at 3 to 6 month Reduced by 50% Among RESPECT-D project patients