Collaborative Care Management of Depression in Primary Care: Making It Work Kurt Angstman MS MD John Wilkinson MD Department of Family Medicine Mark Williams MD David Katzelnick MD Department of Psychiatry and Psychology Mayo Clinic Rochester Minnesota, USA February, 2012

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.

Collaborative Care Management: Making It Work How we developed collaborative care How we developed collaborative care Minnesota Minnesota Mayo Clinic Mayo Clinic Group discussion of collaborative care Group discussion of collaborative care Success of collaborative care Success of collaborative care practical advice practical advice our results so far our results so far Expansion of collaborative care Expansion of collaborative care what we have learned what we have learned

Collaborative Care For Depression Why we needed a new system: Why we needed a new system: Not enough psychiatrists Not enough psychiatrists Or other mental health specialists Or other mental health specialists Inconsistent care Inconsistent care Patients do not start medication Patients do not start medication Patients do not continue medication Patients do not continue medication Patients do not return Patients do not return No registry of patients with depression No registry of patients with depression

Collaborative Care For Depression What is the evidence? “Collaborative care more effective than usual care” Meta-analysis of 37 trials in primary care (US and Europe) Meta-analysis of 37 trials in primary care (US and Europe) Gilbody et al, Archives of Internal Medicine; 2006 Report to President’s Commission on Mental Health Report to President’s Commission on Mental Health Unutzer et al, Psychiatric Services; 2006

DIAMOND: ( Depression Improvement Across Minnesota, Offering a New Direction) New design based on best practices New design based on best practices New method of payment New method of paymentwww.icsi.org

Monthly Payment Covers: Care manager role & tasks Care manager role & tasks Psychiatrist weekly consultation Psychiatrist weekly consultation Up to 2 hrs/wk per full time equivalent care manager with full caseload (approximately 100 patients) Up to 2 hrs/wk per full time equivalent care manager with full caseload (approximately 100 patients) Continues for a year or until patient “graduates” Continues for a year or until patient “graduates”

DIAMOND: Eligibility… 18 years old or older 18 years old or older PHQ-9>=10 PHQ-9>=10 Diagnosis: Diagnosis: Major depression Major depression Dysthymia Dysthymia Minimal exclusion criteria: Bipolar diagnosis Minimal exclusion criteria: Bipolar diagnosis

DIAMOND: 4 New Processes 1.PHQ-9: Consistent tool for diagnosis and monitoring 2.Registry: Tracking system 3.“Stepped care”: intensify or modify treatment 4.Relapse prevention counseling

DIAMOND: 2 New Roles 1.Care Manager follow-up and supportfollow-up and support coordinate carecoordinate care 2.Consulting Psychiatrist reviews patients with Care Managerreviews patients with Care Manager makes recommendations for primary care doctormakes recommendations for primary care doctor

DIAMOND: Each primary care clinic… Hired Care Managers Hired Care Managers Arranged for a Consulting Psychiatrist Arranged for a Consulting Psychiatrist Developed a registry Developed a registry Started using PHQ-9 Started using PHQ-9 Trained primary care doctors Trained primary care doctors Reported data to ICSI Reported data to ICSI

Development of Registry:

DIAMOND: Care Managers Across state, many different care givers in this role Across state, many different care givers in this role Medical Assistants Medical Assistants Licensed social workers Licensed social workers RNs RNs All of our care managers are RN All of our care managers are RN Flexibility in developing team based care Flexibility in developing team based care

DIAMOND: Care Managers Training Training Motivational interviewing Motivational interviewing Stepped care for depression Stepped care for depression Collaborative management Collaborative management Relapse prevention counseling Relapse prevention counseling Experience Experience Noted it was easier for RN with psychiatric background to enter into primary care than visa versa Noted it was easier for RN with psychiatric background to enter into primary care than visa versa

Collaborative Care: Making It Work Care Manager working with psychiatrist Weekly review of patients… All new patients All new patients Any concerns or questions Any concerns or questions Those not improving Those not improving Consultation at any time... acute problems acute problems needs hospitalization needs hospitalization urgent concern by primary care physician urgent concern by primary care physician

DIAMOND: Consulting Psychiatrist New role for psychiatrists: New role for psychiatrists: Reviews patients with Care Manager Reviews patients with Care Manager Makes recommendations on management Makes recommendations on management Disease management oversight rather than direct patient care role Disease management oversight rather than direct patient care role Manage patients in a morning rather than seeing 3-4. Manage patients in a morning rather than seeing 3-4. Less waiting, reviews patients weekly, triage sicker patients sooner Less waiting, reviews patients weekly, triage sicker patients sooner

DIAMOND: Depression Improvement Across Minnesota, Offering a New Direction 2006: started planning 2006: started planning 2008: 5 clinics 2008: 5 clinics 2012: 60 clinics 2012: 60 clinics 8000 patients 8000 patients 23 psychiatrists 23 psychiatrists

Collaborative Care: Making It Work Getting started in DIAMOND PHQ-9 – objective measurement Used for screening Used for screening Used for diagnosis, monitoring Used for diagnosis, monitoring Gives structure to the interview Gives structure to the interview Includes DSM-IV TR criteria Includes DSM-IV TR criteria Assess risk of suicide Assess risk of suicide

Collaborative Care: Making It Work Care Manager working with primary doctor Shares recommendations of psychiatrist Shares recommendations of psychiatrist Verbal or electronic communication Verbal or electronic communication Notifies about inactivation or graduation (from DIAMOND) Assist with management of complications Assist with management of complications Coordination of care for acutely suicidal patients Coordination of care for acutely suicidal patients

Collaborative Care: Making It Work New role for Primary Care Physicians Reviews patients with Care Manager Reviews patients with Care Manager Still responsible for patients Still responsible for patients Writes prescriptions for all therapies Writes prescriptions for all therapies Collaborates with psychiatrist Collaborates with psychiatrist Builds trust and relationships Builds trust and relationships

DIAMOND: Implementation… Reviewed of current practices for depression “Re-design” practice of depression at clinics to incorporate care manager Patients needed to be a part of the process change. “This is the way we manage depression…” “This RN care manager works with me to help our patients get better.”

DIAMOND: Re-design of depression care… Effective screening Patients with mood symptoms or those on antidepressant Not… every patient/ every visit Educational training of primary care in depression diagnosis and care management process Early feedback on new processes and adapt based on outcomes

DIAMOND: New depression work flow After diagnosis of depression (with PHQ-9) and treatment plan initiated. A brief patient review by physician with care manager Care Managers located close proximity to patient care Care Manager evaluation of patient Approximately 45 minutes to complete

Collaborative Care: Making It Work Initial evaluation by Care Manager: Screening also for… Screening also for… alcoholism (AUDIT) alcoholism (AUDIT) anxiety (GAD-7) anxiety (GAD-7) bipolar disorder (MDQ) bipolar disorder (MDQ) Current symptoms and past psychiatric history Current symptoms and past psychiatric history Prior medications, intolerances, etc. Prior medications, intolerances, etc.

DIAMOND: New depression work flow Weekly review of new patients with psychiatrists Electronic communication from care managers to primary care providers Patient concerns Recommendations from psychiatrist

DIAMOND: Re-design of depression care… After achieving remission Patient is given relapse prevention counseling by care manager 45 minute appointment Will have six and twelve month follow up of PHQ-9

Care Management Implementation and workflow re-design Questions?? Comments?? Group Discussion

At Mayo: 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); b_category=7 (accessed Jan 2012) Remission at six months-intent to treat methodology (all in remission/all activated initially); b_category=7 (accessed Jan 2012) b_category=7 b_category=7

“Warm” hand-offs are important Co-morbidities affect improvement and re- admission at 6 months PHQ-9 severity affects outcomes at 6 months Staying in care management is important Early data: cost savings for the health care system Collaborative Care: Making It Work What we have learned:

With “warm” hand-off Without “warm” hand-off Angstman KB, Bender RO, Bruce SM. Patient advisory groups in practice improvement: sample case presentation with a discussion of best practices. J Ambul Care Manage Oct-Dec; 32(4): Angstman KB, Bender RO, Bruce SM. Patient advisory groups in practice improvement: sample case presentation with a discussion of best practices. J Ambul Care Manage Oct-Dec; 32(4):328-32

Regression model of clinical remission (PHQ-9<5) after six months of collaborative care management Angstman KB, Maclaughlin KL, Rasmussen NH, Dejesus RS, Katzelnick DJ. Age of depressed patient does not affect clinical outcome in collaborative care management. Postgrad Med Sep; 123(5): Angstman KB, Maclaughlin KL, Rasmussen NH, Dejesus RS, Katzelnick DJ. Age of depressed patient does not affect clinical outcome in collaborative care management. Postgrad Med Sep; 123(5): Clinical Remission N=574 Odds RatioCIP= Initial PHQ MDQ % Negative GAD

Regression model of re-admission within six months of “graduation” from collaborative care management Angstman KB, MacLaughlin KL, Williams MD, Rasmussen NH, DeJesus RS. Increased Anxiety and Length of Treatment Associated With Depressed Patients Who are Readmitted to Collaborative Care. Journal of Primary Care and Community Health Apr; 2(2):82-6 Angstman KB, MacLaughlin KL, Williams MD, Rasmussen NH, DeJesus RS. Increased Anxiety and Length of Treatment Associated With Depressed Patients Who are Readmitted to Collaborative Care. Journal of Primary Care and Community Health Apr; 2(2):82-6 Re-admission for recurrent depression within six months N=145 Odds RatioCIP= Initial GAD-7 score to Length of time in CCM (in days) to

Regression model of clinical remission (PHQ-9<5) after six months of collaborative care management Angstman KB, Pietruszewski P, Rasmussen NH, Wilkinson JM. Depression Remission after six months of collaborative care management: role of initial severity of depression in outcome. Mental Health in Family Medicine. Submitted for publication Angstman KB, Pietruszewski P, Rasmussen NH, Wilkinson JM. Depression Remission after six months of collaborative care management: role of initial severity of depression in outcome. Mental Health in Family Medicine. Submitted for publication Clinical remission after six months N= 698 Odds Ratio CIP= PHQ-9 Score Moderate (10-14) Mod-Severe (15-19) Severe (>=20) Referent Referent Referent

Effectiveness of staying in collaborative care management Preliminary data: Those who leave care management have significantly lower odds for remission after six months and have increased risk for persistent depression- even in multivariate analysis when controlling for age, gender, race, marital status, intake PHQ-9, MDQ, GAD-7, AUDIT or prior diagnosis of depression Preliminary data: Those who leave care management have significantly lower odds for remission after six months and have increased risk for persistent depression- even in multivariate analysis when controlling for age, gender, race, marital status, intake PHQ-9, MDQ, GAD-7, AUDIT or prior diagnosis of depression N= 1,184 Odds RatioCIP= Six month Remission- if left for any reason < Persistent depression after six months- if left for any reason <0.0001

For every $1.00 spent on DIAMOND at initial two sites… …we saved $1.74 in total mental health expenses (2009 data) Angstman KB, Rasmussen NH, Herman DC, Sobolik JJ. Depression Care Management: Impact of Implementation on Health System Costs. Health Care Manag (Frederick) Apr-Jun; 30(2): Angstman KB, Rasmussen NH, Herman DC, Sobolik JJ. Depression Care Management: Impact of Implementation on Health System Costs. Health Care Manag (Frederick) Apr-Jun; 30(2): Collaborative Care: Making It Work What we have learned:

Core elements of effective treatment: Screening Patient Self-Management Clinician education Simple treatment algorithm Treatment coordinator Mental Health Clinician availability Expansion of Collaborative Care: Making It Work Challenges and what we have learned:

Primary care and mental health still need to learn how to work together – different cultures Care Managers often want to help with many problems, not just depression Should we hire Care Managers for patients with many chronic diseases, not just depression? Expansion of Collaborative Care: Making It Work Challenges and what we have learned:

Guidelines alone do not lead to better outcomes Patient and provider education alone do not improve outcomes Do not increase screening until efficient process of care is in place Proactive care coordination is essential Need to directly deal with concern about suicidal patients Expansion of Collaborative Care: Making It Work Challenges and what we have learned:

Learning from the practice: Cost offset? Cost offset? Who tends to come back for a second treatment? Who tends to come back for a second treatment? What happens to those screening positive on bipolar screening tools (MDQ)? What happens to those screening positive on bipolar screening tools (MDQ)? Proactive approach to those at higher risk Proactive approach to those at higher risk Expansion of Collaborative Care: Making It Work Challenges and what we have learned:

“The process of moving efficacious treatments to usual- care settings is complex and may require adaptations of treatments, settings and service systems.” Schoenwald SK and Hoagwood K. Psychiatric Services 2001; 52:

Expansion of Collaborative Care: Making It Work Expansion of Collaborative Care: Making It Work Characteristics of Rapidly Disseminated Innovations Robust scientific evidence Applicable to many patients or without innovation patients will suffer severe adverse events Cost neutral or savings Raises patient satisfaction Not complicated to implement Fitzgerald L. Health and Social Care in the Community. 2003; 11(3):

Expansion of Collaborative Care: Making It Work Expansion of Collaborative Care: Making It Work Proactive Quality Improvement Tools Plan-Do-Study-Act – PDSA Cycle Six-Sigma “Lean” Methodology Varkey P. Mayo Clin Proc. 2004; 82(6):735-39

Improvement Hold Gains Spread Expansion of Collaborative Care: Making It Work Creating a New System: Improvement Hold GainsSpread BETTER: GOOD:

Expansion of Collaborative Care: Making It Work Creating a New System: “The collaborative care model will not work in my busy practice…”

Expansion of Collaborative Care: Making It Work Creating a New System: Routine use of self-rated scales Train office staff to help with collaborative care Proactive follow up Monitor outcomes Monitor referrals Monitor treatment adherence

Collaborative Care Management of Depression in Primary Care: Making It Work Collaborative Care Management (DIAMOND) translated an evidence based model into practice translated an evidence based model into practice sustainable (cost and outcomes) sustainable (cost and outcomes) Significant improvements Significant improvements Improved access Improved access Improved patient involvement Improved patient involvement Improved communication and trust among primary care physicians and mental health providers Improved communication and trust among primary care physicians and mental health providers

Collaborative Care Management of Depression in Primary Care: Making It Work Start small before spreading to entire clinic Essential to have strong senior leader support Engage Primary Care and Mental Health Specialists as champions Adapt to needs of patients and local resources Both primary care and specialists need to adapt to new model Create team approach Mental health specialists use primary care processes as much as possible After implementation re-assessment based on feedback and outcomes

Questions?? THANK YOU! Dr. Kurt Angstman Dr. Kurt Angstman Department of Family Medicine Department of Family Medicine Dr. Mark Williams Dr. Mark Williams Department of Psychiatry and Psychology Department of Psychiatry and Psychology Dr. John Wilkinson Dr. John Wilkinson Department of Family Medicine Department of Family Medicine Dr. David Katzelnick Dr. David Katzelnick Department of Psychiatry and Psychology Department of Psychiatry and Psychology Chair, Division of Integrated Behavioral Health Chair, Division of Integrated Behavioral Health doc doc