What Does Research Tell Us? Care Manager Roles in Depression Care

Disease Management Improve care for chronic illness (Wagner, Austin, von Korff, M., 1996). Disease management: An intervention designed to manage and prevent a chronic condition by using a systematic approach to care and potentially employing multiple treatment modalities ( Ellrodt, et al.,1997); varies somewhat by project. -Models: Collaborative Care (primary care physicians, psychiatrists, clinical nurse specialists and P-NP’s)

Models (Continued) Evidence-based practice guidelines and multiple modalities (psychosocial and pharmacologic). Care management: (compilation several sources) 1)Assess symptoms of depression 2) Educate patient/ family on depression, treatment and problems solving skills. 3) Monitor for medication adherence, satisfaction 4) Behavioral activation (including motivation) 5) Relapse prevention 6) Communication with participating health personnel: specialist referral, documentation, need for PC assessment.

Credentials of Care Managers Registered and advanced practice nurses* Social workers Psychologists Trained interventionists without health professional licensure * majority of care managers

Making Sense of Research Findings Study goals were heterogenous: patient outcomes vs. health professional outcomes Study samples are small Severity of depression varied Participants at different points of the life span Few minority group members Included face-to-face & telephone interviews Simple to complex interventions

Program Education Systematic Review Badamgarav, et.al disease management programs studied Key aspects of depression care : -detection - prescription of appropriate treatment - patients’ compliance with treatment

Findings Programs had statistically significant effects on: - improvement in symptoms of depression -patients’ satisfaction with treatment -patients’ compliance with treatment -increased rates of depression detection by PCP -increased health care utilization, treatment costs, and hospitalization

Educational and Organizations Systematic Review Gilbody, Whitty, Grimshaw, Thomas,(2003) 36 studies (29 RCT’s,) Effective strategies: Collaborative Care Stepped Collaborative Care Quality Improvement Pharmacy Prescribing Information and Patient Education

Continued Guideline implementation Strategies Case Management (positive results) -medication follow-up by nurses, counselors or psychologists -low intensity nurse involvement (education, counseling, telephone) - trained nurse case management

Findings Elements linked to clinical effectiveness in the short term: - clinician and patient education - nurse case management - enhanced psychiatric services support - monitoring of medication adherence

Recommendations Educate/train primary care physicians and care managers Choose interventionists with aptitudes for active listening, communicating positive regard and empathy Follow standard guidelines (AHCPR) in depression care Further research on intervention components, cost- effective care provision Organizational support

Questions Remain Treatment results: do they depend on treatment alliance of patient and team of providers? What are active ingredients of effective interventions? Can we achieve clinical and cost effectiveness with nurse case management, collaborative care, care management and QI? What interventions work over the long term care?