1. R 63 year old widowed, bible carrying, male truck driver A1c = 9.9% (goal <7%) Blood Pressure = 180/100 (goal <140/90) Cholesterol LDL = 180 (goal < 100) Depression PHQ-9 = 20 (goal < 5) Multiple Medications: – Metformin, Simvastatin,Glipizide XL – Fluoxetine

2. Usual care See patient in office – Address patient major concern (foot pain) – Maybe adjust one or two chronic disease medicines Schedule follow up in 3 months depending on provider availability Repeat I experience frustration because he is negatively impacting my outcomes for Diabetes care

3. Depression is a Primary Care Issue 54% of individuals with a mental health condition are served in primary care 42% of patients with clinical depression are diagnosed by a primary care physician Most individuals prefer to receive their mental health care within the primary care setting since it is perceived as less stigmatizing than the traditional mental health system

4. Depression is depressing …the mean life span in depressed patients is 25 to 30 years shorter than that of the general population

5. Depression in Chronic diseases

6. Care of Mental, Physical, and Substance use Syndromes The project described was supported by Grant Number 1C1CMS331048 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor. 6

7. 7 COMPASS Consortium: Ten National Partners

8. 8 Improve Depression outcomes Diabetes control Hypertension control Increase Clinician satisfaction Patient satisfaction Decrease Costs Unnecessary hospital & ED use Expand Workforce roles Goals of COMPASS

9. 9

10. Key Components—Part 1 A defined care management process Systematic case review teams 10

11. I’m a family physician I’m a psychiatrist Me, too The Systematic Case Review Team discusses both the medical and mental health needs of a patient to build an integrated care plan to achieve patient goals. I’m a care manager 11

12. Key Components—Part 2 Care management tracking system Systematic treatment intensification Monitoring for potentially preventable events Routine data reporting & QI processes

13. Key Drivers of Improvement Systematic treatment intensification Care management tracking system Monitoring for potentially preventable events Routine data reporting and QI processes 13

14. Patient characteristics All had already failed “usual care” in their system Insurance mix –Commercial: 27% –Medicaid 20% –Medicare 47% –Dual 5% Average length of enrollment: 6 months 14

15. Patient characteristics Average age: 59.7 years (range 18-99) Gender mix: 64.3% female Diagnosis 46%-Depression & DM 33%-Depression, DM & HTN 14%-Depression & HTN 15

16. Patient satisfaction with depression care Baseline (N=569) After one year (N=378) Unsatisfied or very unsatisfied 9.5 %6.4 % Neutral22 %15.3 % Satisfied or very satisfied 68.6 %87.9 %

17. Clinician satisfaction Clinician satisfaction with clinic resources Baseline (N=709) One year (N=689) Unsatisfied or very unsatisfied 21.8 %14.3 % Neutral13.3 %15.1 % Satisfied or Very satisfied 65.1%70.6 %

18. Clinical Outcomes ConditionGoals Outcomes Depression Improve control for 40% of patients 61% Showed significant improvement Diabetes Improve control rates by 20% 23% Absolute improvement in patients with A1c <8 Hypertension Improve control rates by 20% 58% With uncontrolled hypertension who achieved measure control March 2015

19. Care of Mental, Physical, and Substance use Syndromes The project described was supported by Grant Number 1C1CMS331048 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor. 19

20. R a 63 year old widowed, male truck driver A1c = 8.7% (goal <8%) (was 9.9%) – Metformin – Glipizide XL – Pioglitazone – Insulin Glargine – (Tried Exanatide unable to tolerate)

21. R a 63 year old widowed, male truck driver Blood Pressure = 126/78 (goal <140/90) (was 180/90) – Lisinopril – HCTZ Cholesterol LDL = 96 (goal < 100) (was 180) Atorvastatin

22. R a 67 year old retired, widowed, male truck driver Depression PHQ-9 = 8 (goal < 5) (was 20) Venlafaxine XL 225 mg once a day Buproprion XL 150 mg once a day Tried Fluoxetine up to 80 mg a day

23. “Depression and Chronic Diseases: It Is Time for a Synergistic Mental Health and Primary Care Approach” Voinov, B, MD, Richie, W.D., MD and Bailey, R, MD Prim Care Companion CNS Disord. 2013; 15(2): PCC.12r01468