depression care: implementing integrated primary care- behavioral health solutions mark dreskin, md...

Depression Care: Implementing Integrated Primary Care-Behavioral

Health Solutions

Mark Dreskin, MD

Depression Care ProgramSouthern California Kaiser

Permanente

Today• Scope of the problem

• Patients in primary care, patients with medical co-morbidities (heart disease, diabetes, other chronic diseases), and screening/identifying cases

• “Treat-to-target” (depression remission) principles in primary care and how to implement (with return on investment, reimbursement)

• Testimonials

Occupational Functioning

• Persons with major depression had a 4.78 greater risk of disability

Broadhead, WE et al, JAMA, 1990;264:2524-2528

• Productivity losses related to depression exceed the costs of effective treatment.

Wang, PS, et al, Am J Psych 2004; 161:1885-1891

What Costs Are Under The Surface?

Harvard Business Review, October 2004

Full Costs – Medical, Pharmacy, Absence and Presenteeism

Recurrence risk

• With initial episodes, the likelihood of future episodes is < 50%, but if left untreated, initial episodes can become chronic, and the higher the number of total episodes, the less likely depression-free intervals will be present at later stages of life

• it is imperative that patients be treated early, and treated all the way to remission, wherever possible

Depression leads to medical morbidity in patients with chronic

diseases

• There is now robust evidence that depressive illness is an independent risk factor in several medical disease states, particularly CVD diseases, and predicts increased morbidity, mortality and healthcare utilization.

Depression leads to medical morbidity in patients with chronic diseases

• Doubles the number of primary care visits/year compared to those who are not depressed

• Doubles the number of hospital days over the expected length of stay compared to non-depressed patients

• 65% of depressed patients receive more than 5 medications

• In diabetes, depression is associated with a 2% increase in glycosylated hemoglobin levels

• (Lustman PJ et al. Gen Hosp Psychiatry.1997; 19:138-143.)

Possible Markers for Depressionin the Medically Ill

• Physical symptoms disproportionate to findings, e.g. multiple pain complaints

• Excess functional disability

• High utilization of medical care

• Poor self-care

• Decreased compliance with medical and/or lifestyle changing regimens

• Reduced social content

Katon W, Sullivan MD. J Clin Psychiatry. 1990;51(suppl 6):311.

Depression leads to medical morbidity in patients with chronic

diseases• BEHAVIORAL FACTORS

• Cigarette Smoking

• Alcohol Consumption

• Poor Diet (excess calories; low nutrient density)

• Sedentary Lifestyle

• Poor Treatment Adherence

• HEALTH PERCEPTION

• one of the highest associations with morbidity and mortality in patients with heart disease and other chronic illnesses (more then smoking or left ventricular ejection fraction in Sperta study)

• strongly correlated with quality of life

• improves with depression treatment

Screening and detection• Depression presents but goes untreated in

general primary care settings

• Only 25% of depressed patients were recognized as such by their primary care physician

• 60-70% of patients with depression present and receive their treatment in primary care and not specialty care

• Though problems of stigmatization and lack of identification are lessening, 40% of these patients still do not receive guideline-based care to effective remission

Treatment Setting: Primary Care vs. Specialty Psychiatry

• Patient preference

• Trust in primary care physician

• Integrated care

• Less stigma

• Lower cost

• Convenience

• Referral may delay initiation of care

Treatment Options in Primary Care

• Watchful Waiting

• May be briefly appropriate in minor depression

• Behavioral Activation

• Encourage exercise and increased activity in mild cases

• Pharmacotherapy (Antidepressant Medications)

• Psychotherapy (Problem-Solving or Cognitive Behavioral)

• Available within primary care in many integrated care programs

• Referral to Specialty Care

• Complicated, severe, non-responding, or suicide risk

and

• medicines plus psychotherapy provide 1.5 times greater chance of full remission, and greatest probability of sustained remission after one year

Other Treatment Options in Primary Care setting

Computer-Assisted Therapy

Psychoeducation

– Depression Classes from Health Education :

Depression Overview – single class

Overcoming Depression – series of 6 classes

Herbal : St. John’s Wort

Proven efficacy in mild depression but preparations may be inconsistent. (though can not be combined with most antidepressant meds)

Bibliotherapy

– eg “Feeling Good” by David Burns

Integrated care

While we list the seven elements individually, there is evidence that it is the integration of these structural elements with each other and with evidence-based clinical practice guidelines that leads to superior patient outcomes. The seven core elements of care are:

1. Treatment Coordination

2. Follow-up/Tracking Systems with Feedback to Practitioners

3. Outcomes Measurement

4. Patient Education and Self-Management Programs

5. Clinician Education

6. Mental Health/Behavioral Medicine Specialist Involvement

7. Detection and Diagnosis Strategies

Psychotherapy

Integrated care

The best outcomes are at sites where an integrated model of care is employed,

following evidence-based guidelines for accurately detecting, diagnosing and treating depression

treatment coordination

consistent and frequent follow-up

opportunity for “stepped care”

outcomes monitoring

patient education

care conferences with liaison psychiatrists

Allow for

care managers following their case loads and surveillance for due dates of actively managed patients

supervisors analyzing the work being done

reporting-out to senior leadership, i.e. for snap shot view of program

for ensuring all patients appropriate follow-up, i.e. per trends in scores, number of treatment trials, high risk factors that require that patient be followed in psychiatry

Studies that have demonstrated enhanced value

Unutzer, IMPACT, 2002

Dietrich, RESPECT trial

PROSPECT trial

Katon, “Partners in Care”

also with dropping BMI in obese patients

also TEAM care (diabetics)




PROSPECT trial




*improve remission rates

* improve compliance

*better patient and physician satisfaction*reduced ED

and clinic utilization




PROSPECT trial




*improve remission rates

* improve compliance

*better patient and physician satisfaction*reduced ED

and clinic utilization

morbidity and mortality

EHR based reportsGive me all

your information

…NOW!

I’m going to go lasso me that

information anytime I need it.

REGISTRY

EHR based reports

Reports only indicated 3 month window

Data entry

3 months

3 months

3 months

3 months

Prompts

Quarterly EHR report

REGISTRY

Snap shot views are “real-time”

Data entry

Prompts

Query

TIDES Study, 2008

90% Hispanic/Latino and Caucasian patients from underserved communities in California

Average age 41 years old

9 demonstration sites, with different levels of proximity, integration

TIDES Study, 2008 The Duke Health Profile

17 item generic self-report standard instrument

Health Measures

Physical health General health

Mental health Perceived health

Social health Self-esteem

Dysfunction measures

Anxiety Depression

Pain Disability

PHQ-9

5-14, consider active treatment

> 15, initiate active treatment

Mean Health Scores

Mean Dysfunction Scores

Changes in PHQ-9 mean scores

Discrepancies exist between instructions that physicians report they communicate to patients and what patients remember being told.

Explicit instructions about expected duration of therapy and discussions about medication adverse effects throughout treatment may reduce discontinuation of SSRI use.

Patients with 3 or more follow-up contacts were more likely to continue using the initially prescribed antidepressant medication, suggesting that frequent contact may increase the probability that patients will continue therapy.

Bull et al, JAMA. 2002;288(11):1403-1409

Likelihood to follow-up on mental health services referral(on 0-5 scale)

Key recent findings

“Stepped Care”

Initial treatment

Switch or augment (A)

Switch or augment (B)

“Last resort” (C)

Initial treatment: SSRI or Problem Solving Therapy

(A)

Switch to other SSRI, SNRI, or PST or other agent

Augment with PST or other agent

(B)

Switch to TCA or other agent

Augment with Lithium, T3 or antipsychotic

Augment with intensive therapy

(C)

MAOi or novel combination

ECT or other interventionRush et al, “STAR*D” study, Arch Gen Psychiatry, 2006

(often steps B & C above are usually done in Specialty Psychiatry setting.)

Factors associated with success

Interpersonal, professional relationship between physical and mental health staff

Co-location better

Consolidated electronic health records

Adequate staff training (especially in treatment of complex patients), both clinical skills, and and effective integrated services

Consistent champions

Factors associated with enhanced value

Use of depression care managers (dedicated to depression care)

Systematic involvement of psychiatrists

On hand for consultation with treating primary care providers

Perform supervision, and provide case review, with depression care managers

“Top down” program development, without “bottom-up” clinic participation

FACTORS ASSOCIATED WITH POOR SUSTAINABILITY

• Difficulty recruiting mental health staff willing to adopt program role

Katon et al, 2010

FACTORS THAT REDUCED CLINIC/PRACTITIONER PARTICIPATION

Quality results from Minnesota DIAMOND-OutcomesResponse and remission rates at 6 month

Offedahl, ICSI

Quality results from Minnesota DIAMOND-Outcomes

Response and remission rates at 12 month

Offedahl, ICSI

Unutzer commentary

Endorsement of “stepped care” (“treat-to-target”)

Back-office staff for core support functions, such as out-reach, tracking, evaluating for treatment side effects

Active dialogue and collaboration between primary care provider and the behavioral health provider

REIMBURSEMENT ISSUES

• Affordable Care Act, issues with planned 2014 implementation

• Medicare-changes had modest effect on how 5 Stars calculated, but will be combination metrics (quality and process metrics) and survey responses from VA/Rand HOS (non specific)

• Patient-centered medical home

• quality metrics including psychiatric in-patient follow-ups, childhood ADHD medication measures, HEDIS anti-depressant medication metrics

Beyond the Mental Health Parity Act

Medicare “Star Ratings” Quality measures

NCQA, HEDIS

Service measures

METEOR, others

Survey measures

Perceived health

Average Impact on MCS Scores Observed in Veterans Health StudyKazis, LE, Miller, DR, Skinner, KM, et al. Patient reported measures of health: The

Veterans Health Study. J of Ambulatory Care Mgmt, 2004; 27:1, 70-83.

Condition Impact on MCS*Hypertension -0.50

Angina -0.64

Diabetes -0.08

Osteoarthritis -2.05

Chronic Low Back Pain

-2.83

Chronic Lung Disease

--

Depression -8.00

Alcohol Disorders -6.59*Impact of disease on MCS controlling for sociodemographic and co-morbid

conditions

testimonials

• a patient who was feeling suicidal received a call from a hospital clinic-based social worker, assigned to do depression program outreach. The patient came to the hospital at the case managers request, and states that it saved his life.

• a patient who received a letter with a questionnaire, from the depression program, states that it brought to light issues he had been afraid to discuss with his doctor

testimonials

• “I’m not crazy!”

• “Who are you?”

• Lesson learned: “Depression care program” sounds a little “cultish”

• To what extent do integrated care programs need to be modified to adopt other populations at risk, i.e. adolescent depression, post-partum depression, axis I illnesses besides depression (substance abuse disorders, anxiety disorders, attention deficit disorder)

• Reimbursable “care extender” training

• New nationally recognized quality measures still up in the air, i.e. screening, follow-up, treatment effectiveness surrogates-(such as PHQ-9 or other quantifiable disease metric)

Future issues:

•APPENDIX

PROGNOSIS & COURSE

• 50% of patients have a single episode of MDD with no subsequent episodes over 20 years of follow-up.

• 15% of subjects have an unremitting course without any true periods of full remission after an index episode

• 35% of subjects have a recurrent disorder with a variable course

Eaton WW et al Arch Gen Psychiatry. 2008;65(5):513-520

Medicare “Star Ratings” Quality measure:

HEDIS medication measures

Meant to ensure that plan coverage keeping patients med adherent

Foye, 2010; Bull et al, 2002

Patient survey data (“Health Outcome Survey)

Mental health wellness

Table 3. Factors Associated With Discontinuing Use of the Initial Antidepressant Medication Within 3 Months of Starting Treatment: Results of Multivariate Model*.

Bull, S. A. et al. JAMA 2002;288:1403-1409Copyright restrictions may apply.

Table 2. Antidepressant Treatment Status 3 Months After Start of Treatment in Relation to Patient-Physician Communication, Medication Adverse Effects, and Clinical

Improvement*.


Table 4. Factors Associated With Switching the Initial Antidepressant Medication Within 3 Months of Starting Treatment: Results of Multivariate Model*.


Medicare Advantage in One Slide

Plans contract with CMS to provide Medicare benefits to beneficiaries as an alternative to traditional Medicare FFS.

Plans receive non-negotiated, risk-adjusted, capitated payment from CMS based on the health status of each individual enrollee.

Plans have some flexibility to selectively contract with providers, do medical management and provide additional care support services.

However, CMS maintains substantial involvement in regulating and monitoring the services being provided by private plans.

VR-12 Questions

Physical Health (Summary Measure)

Mental Health (Summary Measure)

1. Your Health

2a. Moderate Activities 2b.Climbing

Several Stairs

3a. Accomplished

Less3b. Limited in

Kind

4a. Accomplished

Less4. Limited in

Kind

5. Pain Interference

6a. Peaceful6b. Energy6c. Down-

Hearted

7. Interference in Social Activities

9. Change in Emotional

Health

8.Change in PhysicalHealth

SCALES

GeneralHealth

Physical Functioning

Change Emotional

Role-Physical

ChangePhysical

SocialFunctioning

Vitality/MentalHealth

Bodily PainRole-Emotional

Sou

rce:

Lew

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Veterans Rand 12-Item Health Survey (VR-12)

First 12 questions of HOS.

Extensively tested, shown to be reliable and valid in ambulatory care populations.

8 scales of health include mental health.

Physical Functioning,

Role-Physical,

Role-Emotional,

Bodily Pain,

Social Functioning,

Mental Health,

Vitality,

General Health.

6 questions used to calculate the mental health composite score (MCS).

What is the MCS? (Mental Health Composite Score)

The change in a plan’s MCS score from baseline to 2-year follow-up is used to assess a Medicare Advantage (MAO) Plan’s ability to sustain or improve the mental health of its population.

The six questions above are weighted and impact the MCS score, some more than others.

The change in this score is the basis for the CMS Star ratings.

The CMS Star ratings will impact quality bonus payments for Medicare Advantage plans as of 2012.

VR-12 Question 4a & 4b


4a. Accomplished Less

4b Limited in Kind

Role-Emotional

Sou

rce:

Lew

is K

azi

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t. a

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VR-12 Question 6a, 6b, & 6c


6a. Peaceful

6b. Energy

6c. Down-Hearted

Vitality/MentalHealth

Sou

rce:

Lew

is K

azi

s, e

t. a

l

VR-12 Question 7


7. Interference in Social Activities

SocialFunctioning

Sou

rce:

Lew

is K

azi

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t. a

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1) Percentage measurement scores for “Improving and Maintaining Mental

Health”

1. MCS scores are calculated per beneficiary at baseline and follow-up to determine the 2-year change.

2. These “change scores” are aggregated to the plan level and case-mix adjusted to show the percentage of enrollees whose MCS was the same, better, or worse after 2 years.

3. Outliers are identified based on whether a plan performed the same, better, or worse than the national average (statistically significant differences).

5 HOS Mental Health Questions after

VR-12…

Four depression screening questions

Mentally unhealthy days in past 30 days

MECHANISMS (GENERAL)

• Shared vulnerability hypotheses are increasingly popular in the academic literature. These propose an underlying predisposition to BOTH depression and chronic medical conditions, rather than simple cause & effect

CORONARY ARTERY DISEASE

Depression predicts increased risk of atherosclerosis, CHF, arrhythmias, MI and sudden cardiac death; both in previously healthy individuals and in cardiac patients.

Major Depression doubles the risk of an adverse CVD event within 12 months, independent of ejection fraction, HTN or smoking.

Depressed patients have a 4-fold risk of death after MI compared with non-depressed patients.

Both longitudinal observational studies and several prospective clinical trials have clearly shown that these associations persist after controlling for both psychosocial and behavioral risk factors.

Researchers have thus proposed and studied plausible biological mechanisms by which a direct causation effect or shared vulnerability might be mediated.

Also, other chronic illnesses

• AUTO-IMMUNE DISORDERS

• There is increasing interest in cytokine release as the common pathway mediating the linkage of depression and many different medical conditions.

• CHRONIC PAIN

• More than 50% of depressed patients c/o increased somatic pain

• Unfortunately, in our modern world inactivity and increased pain sensitivity are more likely to result in missed work days, disruption of relationships and markedly worse quality of life.

• Less pain after successful use of integrated model

depression care: implementing integrated primary care- behavioral health solutions mark dreskin, md...

Documents

depression treatment

initiation of care slide

mild depression

depression present

depression series

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