Collaborative Care Management for Depression: Using The Team Approach to Improve Quality of Care STFM December 2010 Conference Employee and Community Health Mayo Clinic Rochester, MN

Disclosures We do not have any financial disclosures. We do not have any financial disclosures. We will not be discussing off-label use of medications or devices. We will not be discussing off-label use of medications or devices.

Depression treatment is a “moving target”

Overview Status/Review of current treatment of depression in primary care Status/Review of current treatment of depression in primary care Collaborative Care Management: Collaborative Care Management: what/why/how what/why/how Care Manager Role Care Manager Role Feasibility of model Feasibility of model Expansion to other clinical sites Expansion to other clinical sites Financial implications Financial implications Conclusions Conclusions

Collaborative care (CCM) vs. usual care (UC) at six months Angstman KB, Williams MD. Patients in a depression collaborative care model of care: Comparison of six month cost utilization data with usual care. Journal of Primary Care and Community Health April 2010; 1: Angstman KB, Williams MD. Patients in a depression collaborative care model of care: Comparison of six month cost utilization data with usual care. Journal of Primary Care and Community Health April 2010; 1:

Minnesota HealthScores Remission at six months-intent to treat methodology (all in remission/all activated initially)

Minnesota HealthScores Remission at twelve months-intent to treat methodology (all in remission/all activated initially)

Practice as usual – primary care Minnesota Council of Health Plans report (Feb 2008) Minnesota Council of Health Plans report (Feb 2008) 80 percent of antidepressants are prescribed by primary care physicians 80 percent of antidepressants are prescribed by primary care physicians 45 out of every 1,000 enrollees in MN health plans have a diagnosis of depression 45 out of every 1,000 enrollees in MN health plans have a diagnosis of depression 75% of patients with depression see primary care physician 75% of patients with depression see primary care physician PCP does not detect depression in >50% of patients PCP does not detect depression in >50% of patients Arch. Gen. Psychiatry, 2003 Arch. Gen. Psychiatry, 2003 Only 20-40% of treated patients improve substantially 12 months after diagnosis Only 20-40% of treated patients improve substantially 12 months after diagnosis Arch. Gen. Psychiatry, 1999; Journal of the American Medical Assn., 2003 Arch. Gen. Psychiatry, 1999; Journal of the American Medical Assn., 2003

Process measures: NCQA HEDIS Measures Commercial Plans Measurement Year Percent Acute Phase Antidepressant Continuation Phase Antidepressant Clinician Follow-up The State of Health Care Quality 2005, National Committee for Quality Assurance, Washington, DC. (Antidepressant Medication Management p 24). Available at:

CAN WE DO BETTER??? Institute for Clinical Systems Improvement Institute for Clinical Systems Improvement Working within the state of Minnesota Working within the state of Minnesota Process patterned after “IMPACT” study at U of Washington/Seattle Process patterned after “IMPACT” study at U of Washington/Seattle State of Minnesota State of Minnesota Providers Providers Commercial health care plans Commercial health care plans

What does the evidence say for for Depression What does the evidence say for Collaborative Care for Depression 37 trials of collaborative care for depression in primary care (US and Europe) 37 trials of collaborative care for depression in primary care (US and Europe) Meta-analysis by Gilbody et al, Archives of Internal Medicine; 2006 Meta-analysis by Gilbody et al, Archives of Internal Medicine; 2006 Consistently more effective than usual care Consistently more effective than usual care Unutzer et al, Report to President’s Commission on Mental Health; Psychiatric Services; Unutzer et al, Report to President’s Commission on Mental Health; Psychiatric Services; 2006.

DIAMOND Depression Improvement Across Minnesota Offering a New Direction Depression Improvement Across Minnesota Offering a New Direction Diagnosis of depression or dysthymia and a PHQ-9 score of >=10 Diagnosis of depression or dysthymia and a PHQ-9 score of >=10 Adults patients Adults patients

ICSI Five waves of implementation Five waves of implementation Starting March 2008 Starting March 2008 Initially 5 clinical sites Initially 5 clinical sites Now 85 sites across the state Now 85 sites across the state Many types of practices. Many types of practices. Development of care management code and payments Development of care management code and payments Eight payors across the state included in project Eight payors across the state included in project

Components of the care management model Regular use of a tool (PHQ-9) to screen and follow patients with depression. Regular use of a tool (PHQ-9) to screen and follow patients with depression. Introduction of a care manager for depression Introduction of a care manager for depression Use of an evidence-based algorithm Use of an evidence-based algorithm Availability of a tool to monitor all patients (an electronic registry) and provide useable data Availability of a tool to monitor all patients (an electronic registry) and provide useable data Backup each week of the care manager by Psychiatry Backup each week of the care manager by Psychiatry Relapse prevention for those who reach remission Relapse prevention for those who reach remission

Team members for collaborative care model in DIAMOND Patient Patient Primary Care Provider Primary Care Provider Maintains control of care Maintains control of care RN/LPN/MA care teams RN/LPN/MA care teams Care Manager Care Manager Psychiatrist Psychiatrist Referral specialists Referral specialists Mental health specialists Mental health specialists

New role for psychiatry Traditional consult liaison role is seeing patients identified by primary care providers. Traditional consult liaison role is seeing patients identified by primary care providers. One patient at a time One patient at a time Patients can wait 2-3 months to be seen Patients can wait 2-3 months to be seen New model New model Review patients with care manager & PC Review patients with care manager & PC Many more patients addressed in same time frame Many more patients addressed in same time frame Patient problems are addressed within days of intake Patient problems are addressed within days of intake Can focus on those needing attention Can focus on those needing attention

Care management role Enrolls patients into DIAMOND Coordinates the registry and frequent patient follow- up contacts by phone or in person for: Education Self-management support Facilitation of stepped care therapy Coordination with PCP and Psychiatry Relapse prevention Each 1.0 FTE care manager generally covers ~ patients at various stages of the process.

Care management intake minute process minute process Review of current depression history Review of current depression history Review of past medical/family history Review of past medical/family history Mental and physical health Mental and physical health Medications Medications Social support system Social support system Co-morbid screenings: Co-morbid screenings: AUDIT/GAD-7/MDQ/Suicidal risks AUDIT/GAD-7/MDQ/Suicidal risks

The Perfect Scenario PCP diagnosis a patient with depression and PHQ-9 score is 10 or greater. PCP diagnosis a patient with depression and PHQ-9 score is 10 or greater. Will start patient on treatment Will start patient on treatment Discusses DIAMOND Discusses DIAMOND Patient agrees to participate Patient agrees to participate PCP comes to the Care Manager’s office PCP comes to the Care Manager’s office Gives background, current symptoms and plan Gives background, current symptoms and plan PCP then introduces the Care Manager to the patient PCP then introduces the Care Manager to the patient The initial intake is completed at that time. The initial intake is completed at that time.

Education Medications: action, efficacy, side effects, Serotonin Syndrome, dosages Medications: action, efficacy, side effects, Serotonin Syndrome, dosages Formal complementary therapies: CBT, individual and group therapy, support groups Formal complementary therapies: CBT, individual and group therapy, support groups Informal complementary therapies: exercise, relaxation techniques, anxiety reduction, behavioral activation, socialization Informal complementary therapies: exercise, relaxation techniques, anxiety reduction, behavioral activation, socialization

The Importance of Education Most patients who previously stopped medications stated it was because they weren’t told about possible side effects or the need to remain on medications after remission. Most patients who previously stopped medications stated it was because they weren’t told about possible side effects or the need to remain on medications after remission. Discussing the biochemical benefits of exercise, introducing self-help therapies such as relaxation techniques and CBT helps patients feel like they have some control over their depression. Discussing the biochemical benefits of exercise, introducing self-help therapies such as relaxation techniques and CBT helps patients feel like they have some control over their depression. Discussing therapy options and connecting with resources provides patients with the support needed to learn about themselves and begin to change. Discussing therapy options and connecting with resources provides patients with the support needed to learn about themselves and begin to change.

Self-management Support Assist with setting realistic, attainable, behavioral activation goals Assist with setting realistic, attainable, behavioral activation goals Provide encouragement and positive feedback through motivational interviewing Provide encouragement and positive feedback through motivational interviewing Promote accountability through monitoring progress and/or barriers Promote accountability through monitoring progress and/or barriers Assist with revision of goals as needed Assist with revision of goals as needed

Facilitation of Stepped Care Therapy Follow ICSI guidelines for Treating Major Depression for Adults in Primary Care Follow ICSI guidelines for Treating Major Depression for Adults in Primary Care Monitor medication response, side effects Monitor medication response, side effects Assist with internal or external referrals such as Psychiatry consultation, therapy consultation, human services, community agencies Assist with internal or external referrals such as Psychiatry consultation, therapy consultation, human services, community agencies

Care Managers and Referrals Many times patients are not improving because of their life situations that medications can’t fix. Many times patients are not improving because of their life situations that medications can’t fix. When a patient is not getting better, the Care Manger often needs to refer the patient to community resources, which can make a big impact on their lives and their depression. When a patient is not getting better, the Care Manger often needs to refer the patient to community resources, which can make a big impact on their lives and their depression. Parenting support groups Parenting support groups Grief support groups Grief support groups Food pantries Food pantries Free medication clinics Free medication clinics Life coaches Life coaches Social workers, etc. Social workers, etc.

Coordination with PCP Initial review of patient’s symptoms, brief history, treatment plan at enrollment Initial review of patient’s symptoms, brief history, treatment plan at enrollment Notification of medication side effects, increased suicidality, any new concerns Notification of medication side effects, increased suicidality, any new concerns Requests for medication dosage adjustments, anxiety management, or sleep enhancement as needed Requests for medication dosage adjustments, anxiety management, or sleep enhancement as needed Requests for complementary therapy orders such as light box, group therapy, individual therapy, psychiatry consult Requests for complementary therapy orders such as light box, group therapy, individual therapy, psychiatry consult Notification of any recommendations made by Psychiatry Notification of any recommendations made by Psychiatry Notification of inactivation or graduation from program Notification of inactivation or graduation from program

Coordination with Psychiatrist Coordination with Psychiatrist Weekly review with psychiatrist: Weekly review with psychiatrist: All newly enrolled patients All newly enrolled patients Patients the Care Manager or PCP has concerns about Patients the Care Manager or PCP has concerns about Patients who are not improving Patients who are not improving Any PCP requests for treatment recommendations Any PCP requests for treatment recommendations Consult with covering Psychiatrist at any time to discuss acute concerns, patients needing hospitalization, or PCP requests Consult with covering Psychiatrist at any time to discuss acute concerns, patients needing hospitalization, or PCP requests

Helping The Suicidal Patient A patient came to the front desk with thoughts of driving her car into a tree and so she came to the Clinic instead of going to work. A patient came to the front desk with thoughts of driving her car into a tree and so she came to the Clinic instead of going to work. Contacted the DIAMOND Psychiatrist, who had reviewed the patients history during supervision the week before. He recommended a direct admission to the Mental Health Unit in the hospital. Contacted the DIAMOND Psychiatrist, who had reviewed the patients history during supervision the week before. He recommended a direct admission to the Mental Health Unit in the hospital. Reviewed with the PCP about the situation and recommendations. The PCP stopped into the room and reassured the patient before she left for the hospital. Reviewed with the PCP about the situation and recommendations. The PCP stopped into the room and reassured the patient before she left for the hospital. These situations happen frequently and we are able to help the patient avoid unnecessary visits to the ER through immediate access to Psychiatry consultation, and help the PCP by arranging admission. These situations happen frequently and we are able to help the patient avoid unnecessary visits to the ER through immediate access to Psychiatry consultation, and help the PCP by arranging admission.

Relapse Prevention Once patient meets graduation criteria Once patient meets graduation criteria Clinical remission x 2 months Clinical remission x 2 months PHQ-9 < 5 PHQ-9 < minute process with care manager minute process with care manager Time course for medications Time course for medications Warning signs Warning signs Motivational interviewing Motivational interviewing Follow up 12 months) Follow up 12 months)

Graduation Visit Discuss the recommended time he/she remains on antidepressant and need to taper when discontinuing with PCP recommendations Discuss the recommended time he/she remains on antidepressant and need to taper when discontinuing with PCP recommendations Make sure the patient is able to recognize his/her individual symptoms which would indicate relapse and discuss the need to seek early intervention Make sure the patient is able to recognize his/her individual symptoms which would indicate relapse and discuss the need to seek early intervention Discuss the importance of continuing behavioral activation activities such as exercise, socialization, therapy, etc. Discuss the importance of continuing behavioral activation activities such as exercise, socialization, therapy, etc. Encourage the patient to contact the care manager at any time with questions or concerns. Encourage the patient to contact the care manager at any time with questions or concerns.

The Best Part Depression Care Management does make a difference. We see our patients get better every day and they are very thankful. Depression Care Management does make a difference. We see our patients get better every day and they are very thankful. Some patient comments: Some patient comments: “Just knowing you are there if I need you helps me feel better” “Just knowing you are there if I need you helps me feel better” “I personally, am extremely grateful for the Diamond Program. When I was very depressed and on medication, it was not enough for me. Then I was introduced to this program and to Heather. It is a wonderful program! Thank you so much, from the bottom of my heart.” “I personally, am extremely grateful for the Diamond Program. When I was very depressed and on medication, it was not enough for me. Then I was introduced to this program and to Heather. It is a wonderful program! Thank you so much, from the bottom of my heart.” "I told my friends about your program. I told them I have never had anyone care enough to call and check on me before. They all wanted to know how to sign up.“ "I told my friends about your program. I told them I have never had anyone care enough to call and check on me before. They all wanted to know how to sign up.“ "It's so good to know I have someone on my side“ "It's so good to know I have someone on my side“ It’s not that we do great things, but we do many little things to give support and bring hope to our patients. It’s not that we do great things, but we do many little things to give support and bring hope to our patients.

Diamond FTE NW Clinic February 2010 Care Management Care Management Patient Care1.45 Patient Care1.45 Billing.05 Billing.05 Registry.28 Registry.28 Psychiatry.10 Psychiatry.10 Supervision.14 Supervision.14 NW Clinic: 128 patients enrolled, 20 working days, 18 Providers, 19,000 paneled patients in total,

Finances ICSI ICSI Partnerships Partnerships Many insurance providers including BCBS Many insurance providers including BCBS Each Facility negotiating bundled fees Each Facility negotiating bundled fees Designated ICD-9 Codes Designated ICD-9 Codes 296.2x Major Depression Single Episode 296.2x Major Depression Single Episode 296.3x Major Depression Recurrent 296.3x Major Depression Recurrent 300.4Dysthymia 300.4Dysthymia CPT Code T2022 CPT Code T2022 Case Management per Month Case Management per Month Medicaid (will cover in the state of MN) Medicaid (will cover in the state of MN) Medicare considering coverage Medicare considering coverage Covers 50% of our expenses Covers 50% of our expenses

Not included in the bundle Services billed separately (“fee for service”) Services billed separately (“fee for service”) Office visits/contacts with the primary care physician Office visits/contacts with the primary care physician Care by mental health providers Care by mental health providers

Covered Services Payment continues for up to one year, or until the patient reaches remission (two months of PHQ-9 <5). Payment continues for up to one year, or until the patient reaches remission (two months of PHQ-9 <5). Can petition for more time Can petition for more time Patient can be re-enrolled after being off care management for one month for another year. Patient can be re-enrolled after being off care management for one month for another year. Payment designed carefully (antitrust) Payment designed carefully (antitrust) ICSI studied Medical group costs and ROI ICSI studied Medical group costs and ROI

Billing Process Last day of every month Last day of every month Patients that have been activated or active during that month Patients that have been activated or active during that month Internal verification of plan coverage's prior to submission Internal verification of plan coverage's prior to submission Payment is then the responsibility of the plan not the patient Payment is then the responsibility of the plan not the patient Each medical groups designs its own verification process. Each medical groups designs its own verification process.

Mental Health Depression Episodes of Care by Cost MMSI Rank of Top Episodes of Care by Cost Rank of Top Episodes of Care by Cost First 6 months th First 6 months th First 6 months 2010 – 9 th First 6 months 2010 – 9 th Reduction of Mental Health Depression Services Cost by 33% PMPM Reduction of Mental Health Depression Services Cost by 33% PMPM

Change in Mental Health PMPM as % of Total PMPM before and after care management implementation

What have we learned?? Team process dependent Team process dependent “Warm hand off” “Warm hand off” Interaction of psychiatry with PCP Interaction of psychiatry with PCP Interaction of PCP and care managers Interaction of PCP and care managers Psychiatry shifts focus from direct patient care to Care Management supervision Psychiatry shifts focus from direct patient care to Care Management supervision

What have we learned?? Personnel dependent Personnel dependent RN vs. behavioral health vs. MA RN vs. behavioral health vs. MA Not all care managers are the same Not all care managers are the same The challenge: Easier for… The challenge: Easier for… A CM with a psych background to come into primary care? Or… A CM with a psych background to come into primary care? Or… A CM from primary care to learn psychiatry? A CM from primary care to learn psychiatry?

What have we learned?? Care Manager roles Care Manager roles Patient volumes for other disease care management: ~ 500 patients Patient volumes for other disease care management: ~ 500 patients Target for Depression CM: Target for Depression CM: Intention to treat model Intention to treat model Intensive 4-6 months- then can “graduate” Intensive 4-6 months- then can “graduate” Need to develop IT support for alternative mechanisms of communication Need to develop IT support for alternative mechanisms of communication

Conclusions Care Management with team approach of care managers, psychiatry and family medicine docs Care Management with team approach of care managers, psychiatry and family medicine docs Improves access to care Improves access to care Improves patient involvement Improves patient involvement Improves communication Improves communication Multi-specialty/role team development Multi-specialty/role team development Integration of care managers into processes of clinic improves activation, clinical response, patient compliance Integration of care managers into processes of clinic improves activation, clinical response, patient compliance

Mayo Diamond Team Members Dr. Mark Williams, Psychiatry Dr. Mark Williams, Psychiatry Dr. Kurt Angstman, Family Medicine Dr. Kurt Angstman, Family Medicine Dr. Steven Bruce, Family Medicine Dr. Steven Bruce, Family Medicine Dr. Jay Mitchell, Family Medicine Dr. Jay Mitchell, Family Medicine Dr. John Wilkinson, Family Medicine Dr. John Wilkinson, Family Medicine Dr. Ramona DeJesus, Primary Care Internal Medicine Dr. Ramona DeJesus, Primary Care Internal Medicine Dr. Marcie Billings, Community Pediatrics Dr. Marcie Billings, Community Pediatrics Mr. Rob Bender, Operations Manager Mr. Rob Bender, Operations Manager Stephanie Witwer, Nursing Administration Stephanie Witwer, Nursing Administration

Questions?? THANK YOU! Dr. Kurt Angstman, Family Medicine Dr. Kurt Angstman, Family Medicine Robert Bender, Operations Manager Robert Bender, Operations Manager Heather Marker, Depression Care Manager Heather Marker, Depression Care Manager