Primary Care Based Disease Management VISN 4 MIRECC VA Philadelphia University of Pennsylvania

MIRECC – VISN 4 Delivering Quality MH Care in Primary Care  Epidemiology  Chronic Disease Model  Barriers to quality care  Tools / models to improve quality

MIRECC – VISN 4 Psychiatric Disorders in Primary Care  Diagnoses »Depressive disorders »Anxiety Disorders (PTSD in the VA) »Problem Drinking »Illicit Drugs (VA) »Cognitive Disorders (elderly)  Clinical Features »Common »Often milder than cases seen in behavioral health »Associated with significant suffering, morbidity, disability, excess utilization, and mortality

MIRECC – VISN 4 Barriers to Quality MH Care  Beliefs, experience, and expectations of patients and providers  Silos of care  Competing demands for providers and patients  Disincentives for the implementation of chronic care model

MIRECC – VISN 4 Performance Past Screening FY 04FY05 Screened for Depression9495 Screened for Alcohol Misuse9293 Screened for PTSD5841 Follow-up on positive screens Depression5856 Alcohol misuse4249 PTSD4044 Depression Guideline care1214 Brief Interventions 10 *

MIRECC – VISN 4 Tools / Models of Care  Education of providers on best practice »Guidelines, CMEs, seminars, etc.  Enhancing referral mechanisms  Provider Adjuncts »Disease management specialist »Technological assists

MIRECC – VISN 4 Three Examples of Research to Enhance Treatment Outcomes  PRISME Study  NIMH PROSPECT Study  Telephone Disease Management  Behavioral Health Laboratory

MIRECC – VISN 4 Timeline of activity in Primary and Specialty Care Penn Dep Ds Mgt PRISM-E PROSPECT BHL TDM II DIADS ExTENd WW 3/03 UPBEAT Analysis TDM I 6/97 10/99 MIRECC PRISM-EBHL Depression Monitoring

MIRECC – VISN 4

Study Design  Randomized trial comparing integrated (collaborative) care to referral care  Target conditions »Depression »Anxiety »At-risk Drinking  Study Phases »Screening »Baseline assessment »Follow-up assessments at 3 and 6 months

MIRECC – VISN 4 Treatment Arms  Referral Care »Direct referral to specialty psychiatry (most programs used geriatric specialty mental health programs for all subjects) »Enhancements were made at many sites including appointments within 2 weeks, transportation, reduced or no patient costs »Sites were encouraged to deliver guideline adherent care but no specific treatment was mandated  Integrated (collaborative care) »All sites had staff trained in Brief Alcohol Interventions »Some sites used standardized depression protocols others were optimal clinical care Levkoff S., et. al. (2004)

MIRECC – VISN 4 Engagement in treatment by condition Integrated Care Referral Care Odds Ratio Depression75 %52 %2.86 [2.26,3.61] Anxiety71 %56 %1.93 [0.69, 5.40] At-risk Drinking61 %34 %3.09 [2.07, 4.63] Overall71 %48 %2.84 [2.35, 3.43] Engagement = at least one contact with the mental health specialist.

MIRECC – VISN 4

Preliminary Findings from PROSPECT An NIMH supported study on Prevention of Suicide in Primary Care Elderly: Collaborative Trial

MIRECC – VISN 4 THE TWO PREMISES OF PROSPECT’S INTERVENTION 2. Guidelines alone do not ensure both correct physician decisions and patient adherence to treatment. depression specialist PROSPECT has added a “depression specialist” to: timely and targeted assist the physician by providing timely and targeted patient-specific clinical strategies encourage patient adherence to treatment through education and support. 1. Effective treatments for depression exist: PROSPECT has operationalized AHCPR guidelines for use in primary care with the elderly

MIRECC – VISN 4 PROSPECT PROSPECT Percent with > 50% reduction in HDRS/24 Scores Among Patients with MDD P=.001 P=0.01P=0.2

MIRECC – VISN 4 Telephone Based Interventions  Telephone Disease Management is algorithm driven care delivered by a Behavioral Health Specialist.  Enhanced Usual care. The PCP can monitor, treat, and/or refer. The PCP is provided a diagnosis and references for treatment options.

MIRECC – VISN 4 Baseline Characteristics Usual Care Subjects TDM Subjectsp (n=51)(n=46) Age61.9 (11.3)61.3 (10.3)0.775 Gender (% Male) Race (% Caucasian) Marital Status (% married) Currently smokes (%) Cases of depression (%) Cases of at-risk drinking (%) Cases from Primary Care (%)

MIRECC – VISN 4 Improvements with TDM Oslin, et. al. 2003

MIRECC – VISN 4 VA Performance Measures for 2004  Mental Health Performance Measures for 2004 »VA Measures are modeled after HEDIS measures »Apply to patients with New diagnosis of depression New treatment with antidepressant medication »Measures probe the quality of acute phase (12 wk) tx % with > 3 clinical follow-up visits –Only 1 visit can be by telephone –At least 1 must be with the prescribing MD % who receive adequate medication for 84 days

MIRECC – VISN 4 Depression Care Monitoring  Diagnosis and decision to treat  Baseline assessment (from BHL)  Prescription of antidepressant  Follow-up assessment in 1-2 weeks »With provider or designate Educational Check on adherence Check on side effects  Follow-up assessments at 6 and 10 weeks by BHL  Follow-up in-person assessments with MD at the conclusion of an episode of care »If remission, discuss continuation treatment »If no response by 6 weeks, modify treatment »If residual symptoms at 12 weeks, modify treatment.

MIRECC – VISN 4 Care Management  Motivational based brief intervention for enhancing adherence and retention »Pilot of 20 patients – 70% treatment engagement

Telephone Disease Management VISN 4 MIRECC VA Philadelphia University of Pennsylvania

MIRECC – VISN 4 Purpose  To develop a method for delivering high quality depression and alcoholism treatment in Primary Care, CBOCs, and other clinics in which there are significant transportation, staff resource, or other impediments to the delivery of face-to-face MH/SA care.  To develop methods for translating effects demonstrated in randomized clinical trials to clinic populations.

MIRECC – VISN 4 Who is Appropriate?  Inclusion criteria »DSM-IV Major Depression »Age »MMSE > 18 »Hearing and language adequate for participation  Exclusion criteria »Alcohol dependence »Other substance abuse »Current psychosis »Suicidal ideation »History of primary psychosis »History of (hypo)mania

MIRECC – VISN 4 The Role of the Behavioral Health Specialist The role of Behavioral Health Specialist (BHS) is to influence adherence to guidelines by providing "on-­time, on ‑ target" information to primary care physicians and collaboratively make appropriate care decisions.

MIRECC – VISN 4 Integration of Care with the Supervising Psychiatrist

MIRECC – VISN 4 Initial Assessment 1. Review of physician progress notes 2. History of psychiatric and medical conditions 3. List of current medications 4. History of use of psychotropic medications 5. Recent laboratory and neuroimaging reports 6. Record information on initial progress note

MIRECC – VISN 4 Initial contact - Goals  Begin to establish rapport in order to build a supportive and therapeutic relationship.  Review the purpose of the phone call and the reasons for the referral.  Conduct a semi-structured clinical interview in order to learn the patient’s perception of his or her problem and the clinician’s assessment of the presenting problem. (PHQ-9, Beck Anxiety Scale (if warranted), alcohol/substance use and the UKU for side effects)  Begin to develop a hypothesis of the patient’s diagnosis  Complete a Choose a treatment algorithm based on the outcome of the interview  Consult with the primary physician regarding the proposed treatment plan.  Consult with the psychiatrist if needed.  Discuss the proposed treatment plan with the patient, using motivational techniques  Educate the patient regarding medications, if any, that are ordered.  Set up a follow-up phone call with the patient and the BHS for one week later.  Schedule a follow-up visit  Complete a baseline progress note.

MIRECC – VISN 4 Motivating the Patient for Treatment  Assist the individual in recognizing their symptoms and developing an interest in addressing the symptoms.  Motivational Interviewing helps to resolve ambivalence so that the patient can make a decision to accept and adhere to treatment suggestions.  It is a supportive, respectful approach

MIRECC – VISN 4 Roadblocks  Religious  Self-Change  Denial

MIRECC – VISN 4 Key Points  Avoid arguments with the Patient  Express Empathy  Support Self-Efficacy  Roll with Resistance  Develop Discrepancy (help the patient identify where they are now and where they want to be in the future)

MIRECC – VISN 4 Determining a Treatment Plan 1. Monitoring (but not treating) some patients. 2. Treatment by the physician and BHS within protocol guidelines. 3. Delay initiation of treatment algorithms pending further medical stabilization, patient/family approval, or further diagnostic assessment or consultation. 4. Referral for a consultation and/or treatment of patients with complicated diagnostic presentations, chronic benzodiazepine use, severe cognitive impairment, need for hospitalization, or primary psychotic illnesses.

MIRECC – VISN 4 Acute Phase of Treatment for Depressive Disorders BaselineWeek 1Week 3Week 6Week 9Week 12 PHQ-9XXXXXX UKUXXXXXX Medication profile XXXXXX Clinical NoteXXXXXX Substance abuseXXX

MIRECC – VISN 4 Maintenance Phase  Asymptomatic or minimally symptomatic (PHQ-9 score of 10 or less) - continuing pharmacotherapy of six months duration.  During maintenance therapy, meet once a month to obtain clinical ratings.  During the maintenance phase, if a patient scores 10 or greater on the PHQ-9, s/he should be reassessed one week later. If the PHQ-9 score remains at 10 or greater, the patient may be relapsing; therefore, the BHS should consult with the physician and/or supervising psychiatrist. The patient may need to restart the acute phase of the study.

MIRECC – VISN 4 End of Treatment Procedure for Maintenance Therapy  Siscuss with the patient her/his interest in continuing to take medication for relapse prevention.  Patients who continue taking it are less likely to have a relapse than those who discontinue it.

MIRECC – VISN 4 Adverse Event Documentation  During each phone contact, the BHS will initially ask patients if they are having any problems with their medication in an open- ended fashion.  The BHS will proceed with administration of the UKU Side Effects Rating Scale. CNSGastrointestintinalOther SomnolenceNauseaSweating InsomniaDry mouthAbnormal Ejaculation TremorDiarrhea

MIRECC – VISN 4 Key Decision Points **Week 6  If PHQ-9 score is >10, »and NOT reduced 25% from baseline evaluation »or if patient is actively suicidal ***Week 12  If PHQ score is >5, »And NOT reduced 30% from baseline evaluation »or if patient is actively suicidal

MIRECC – VISN 4 Psychopharmacologic Algorithms

MIRECC – VISN 4 General Principles  Substitution, rather than augmentation  Psychotherapy may be used as alternative to pharmacotherapy (Psychotherapy alone) or be combined with antidepressants (augmentation).  Drugs that are simpler to implement in primary care are favored over drugs of known efficacy, but which require special procedures,  Treatments that are often poorly tolerated are given lower priority than treatments that are more likely to be tolerated, even when the efficacy of the latter treatments may be less well-established, e.g., bupropion augmentation of SSRI's was favored over lithium augmentation of SSRI's,  Venlafaxine/Bupropion will be the preferred treatment for patients who appear to be refractory.  When following each algorithm, clinical judgment can override the algorithm.  BHS clinicians are encouraged to discuss these cases with the supervising psychiatrist.

MIRECC – VISN 4 6 Week Response change in PHQ Optimize (max. dose) dose Venlafaxine XR 200 mg/d Buproprion SR 150 mg BID < 30 % change Continue 12 Week Response Maintenance Treatment Physician Choice > 50 % % Skip to 12 week response box PHQ > 5 and < 50 % change in PHQ PHQ < 5 PHQ > 5 and 50 + % change in PHQ 6 Week Response change in PHQ Optimize (max. dose) dose < 30 % change Maintenance Treatment > 50 % % Skip to 12 week response box 6 Week Response 12 Week Response PHQ < 5 PHQ > 5 D/C Bupropion and Augment with nortriptyline plasma levels ng/ml X 6 weeks 6 Week Response Continue Augment with Bupropion SR 150 mg BIDX 6 weeks Maintenance Treatment PHQ < 5 PHQ > 5 unspecified

MIRECC – VISN 4 High Risk Management Protocol  Be very attentive  Remain calm and non-threatened  Give the patient some space and time to vent  Stress a team approach to the problem  Be willing to say the word “suicide” without flinching