Prevention-Research Centers Health Aging Research Network (PRC-HAN) Webinar

Prevention-Research Centers Health Aging Research Network (PRC-HAN) Webinar

Prevention-Research Centers Health Aging Research Network (PRC-HAN) Webinar Series Evidence-Based Depression Care Management: Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) Tuesday, October 16th 2008 2-3:30 PM EST Moderated by: Cate Clegg Jrgen Untzer, MD, MPH, MA Virna Little, PsyD, LCSW-R Sponsors: Prevention Research Centers-Healthy Aging Research Network Retirement Research Foundation National Council on Aging

2 IMPACT Primary Care Based Team Care for Late-Life Depression Jrgen Untzer, MD, MPH, MA Professor & Vice Chair Psychiatry & Behavioral Sciences University of Washington Virna Little, PsyD, LCSW-R Vice President for Psychosocial Services and Community Affairs Institute for Family Health 3 Depression Common 10% in primary care Disabling #2 cause of disability (WHO) Expensive

50-100% higher health care costs Deadly Over 30,000 suicides / year 4 Depression is deadly Older men have the highest rate of suicide. 5 Depression is often not the only health problem Cancer Chronic Pain 10-20% 40-60% Depression Geriatric Syndromes 20-40% Heart

Disease 20-40% Neurologic Disorders 10-20% Diabetes 10-20% 6 Efficacious treatments for depression Antidepressant Medications Over 20 FDA approved Psychotherapy CBT, IPT, PST, brief dynamic, etc. Other somatic treatments ECT Physical activity / exercise Unutzer et al, NEJM 2008.

7 But: few older adults get effective treatment Only half are recognized a particular problem for older men & minorities I didnt know what hit me I am not crazy Isnt depression just a part of normal aging? Fewer than 10 % seek care from a mental health specialist. Most prefer their primary care physician. 8 Depression Treatment in Primary Care 50 % are recognized and started on treatment or referred Limited access to evidence-based psychosocial treatments (psychotherapy) Increasing use of antidepressants

PCPs prescribe 70 90 % of antidepressants 10 - 30 % of older adults are on antidepressants MAJOR OPPORTUNITIES for Quality Improvement even for nonprescribing providers But treatment is often not effective Only 20 40 % improve substantially over 12 months 9 Why integrate care? Home & Community based social services? Primary Care PC Alcohol & substance

abuse care? CM HC Community Mental Health Center 10 Depression Care Management in Primary Care Limited access to / use of mental health specialists Treat mental health disorders where the patients are - Established provider-patient relationship - Less stigma - Better coordination with medical care 11

Components of evidence based integrated care programs Screening / case finding Patient education / self-management support Support medication treatment prescribed in primary care Monitor adherence, side effects, effectiveness [Nonprescribing providers function as the eyes and ears of the doctor] Proactive outcome measurement / tracking e.g., PHQ-9, GDS, CES-D Brief counseling (e.g., Behavioral Activation, PST-PC, IPT, CBT) Stepped care (initial treatments often are not enough) increase treatment intensity as needed mental health consultation to help guide or provide care for patients not responding as expected 12

IMPACT Study Funded by John A. Hartford Foundation California Healthcare Foundation Robert Wood Johnson Foundation Hogg Foundation 13 IMPACT Team None of us is as smart as all of us Study coordinating center Jrgen Untzer (PI), Sabine Oishi, Diane Powers, Michael Schoenbaum, Tom Belin, Linqui Tang, Ian Cook. PST-PC experts: Patricia Arean, Mark Hegel Study sites University of Washington / Group Health Cooperative Wayne Katon (PI), Elizabeth Lin (Co-PI), Paul Ciechanowski Duke University Linda Harpole (PI), Eugene Oddone (Co-PI), David Steffens Kaiser Permanente, Southern CA (La Mesa, CA) Richard Della Penna (Co-PI), Lydia Grypma (Co-PI), Mark Zweifach, MD, Rita Haverkamp, RN, MSN, CNS Indiana University

Christopher Callahan (PI), Kurt. Kroenke, Hugh. Hendrie (Co-PI) UT Health Sciences Center at San Antonio John Williams (PI), Polly Hitchcock-Noel (Co-PI), Jason Worchel Kaiser Permanente, Northern CA Enid Hunkeler (PI), Patricia Arean (Co-PI) Desert Medical Group Marc Hoffing (PI); Stuart Levine (Co-PI) Study advisory board Lisa Goodale (NDMDA), Rick Birkel (NAMI), Thomas Oxman, Kenneth Wells, Cathy Sherbourne, Lisa Rubenstein, Howard Goldman 14 Study Methods 1998 2003 Randomized controlled trial 8 health care organizations in 5 states 18 primary care clinics 1,801 older adults with major depression or chronic depression 450 primary care providers Patients randomly assigned to IMPACT or usual care Usual care = antidepressant Rx in primary care (~ 70 %) and / or referral to mental health specialists (20 %)

All followed with independent assessments for 2 years 15 IMPACT Team Care Model Prepared, Pro-active Practice Team Informed, Activated Patient Effective Collaboration Photo credit: J. Lott, Seattle Times Photo: Courtesy D. Battershall & John A. Hartford Foundation Practice Support 16 Evidence-based team care for depression TWO NEW TEAM MEMBERS TWO PROCESSES 1. Systematic diagnosis and outcomes tracking e.g., PHQ-9 to facilitate diagnosis

and track depression outcomes 2. Stepped Care a) Change treatment according to evidence-based algorithm if patient is not improving b) Relapse prevention once patient is improved Care Manager Consulting Psychiatrist - Patient education / self management support - Caseload consultation for care manager and PCP (population-based) - Close follow-up to make sure pts dont fall through the

cracks - Diagnostic consultation on difficult cases - Support antidepressant Rx by PCP - Consultation focused on patients not improving as expected - Brief counseling (behavioral activation, PST-PC, CBT, IPT) - Facilitate treatment change / referral to - Recommendations for additional treatment / referral according to evidence-based guidelines 17 Treatment Protocol

Assessment and education, Behavioral Activation / Pleasant Events Scheduling AND (3) a) Antidepressant medication usually an SSRI or other newer antidepressant OR b) Problem Solving Treatment in Primary Care (PST-PC) 6-8 individual sessions followed by monthly group maintenance sessions (4) Maintenance and Relapse Prevention Plan for patients in remission 18 Stepped Care Systematic follow-up & outcomes tracking Patient Health Questionnaire (PHQ-9) The cheap suit Treatment adjustment as needed - based on clinical outcomes - according to evidence-based algorithm - in consultation with team psychiatrist

Relapse prevention 19 20 Greater Satisfaction with Depression Care (% Excellent, Very Good) Usual Care 100 P=.2375 Intervention P<.0001 P<.0001 percent 80 60

40 20 0 0 3 month 12 21 Untzer et al. JAMA. 2002; 288: 2836-2845. IMPACT Doubles Effectiveness of Depression Care 50 % or greater improvement in depression at 12 months Usual Care 70 IMPACT 60 50

% 40 30 20 10 0 1 2 3 4 5 6 7 Participating Organizations 8

22 Evidence-based Care Benefits Disadvantaged Populations 50 % or greater improvement in depression at 12 months 60% 50% 54% 43% 42% IMPACT Care 40% 30% 19% 23% Care as Usual 14%

20% 10% 0% White Black Latino Aren et al. Medical Care, 2005 23 Improved Physical Functioning SF-12 Physical Function Component Summary Score (PCS-12) P<0.01 41 P<0.01 P<0.01 P=0.35 40.5

40 Usual Care IMPACT 39.5 39 38.5 38 Baseline 3 mos 6 mos 12 mos 24 Callahan et al. JAGS. 2005; 53:367-373. Fewer thoughts of suicide 18 % patients with suicidal

thoughts 16 14 12 10 IMPACT Usual Care 8 6 4 2 0 Baseline 6 months 12 months 25 Untzer et al, JAGS 2006 IMPACT Saves Money

Intervention group cost in $ Usual care group cost in $ Difference in $ 522 0 522 661 558 767 -210

7,284 6,942 7,636 -694 Other outpatient costs 14,306 14,160 14,456 -296 Inpatient medical costs 8,452 7,179 9,757

-2578 Inpatient mental health / substance abuse costs 114 61 169 -108 31,082 29,422 32,785 -$3363 Cost Category 4-year

costs in $ IMPACT program cost Outpatient mental health costs Pharmacy costs Total health care cost Savings 26 Unutzer et al. Am J Managed Care 2008. IMPACT Summary - Less depression IMPACT doubles effectiveness of usual care - Less physical pain - Better functioning - Higher quality of life - Greater patient and provider satisfaction

- More cost-effective Photo credit: J. Lott, Seattle Times I got my life back 27 IMPACT Endorsements Presidents New Freedom Commission on Mental Health National Business Group on Health Institute of Medicine (Retooling for An Aging America) POGOe CDC Consensus Panel Annapolis Coalition Partnership to Fight Chronic Disease SAMHSA NREPP Commonwealth Fund Integrated Behavioral Health Partnership

28 Taking IMPACT from Research to Practice Support from JAHF (2004-2009) Over 170 clinics have implemented core components of the program to date DIAMOND program in Minnesota implementing the program state-wide in partnership with 25 medical groups and 9 health plans Several large health plans and disease management organizations are incorporating core components of IMPACT 29 IMPACT Implementation Trained over 3000 Over 3,000 clinicians Providers intrained over 150 practices to date 2004

2005 2006 2007 30 2008 Kaiser Permanente of Southern California Pilot Study - Compare 284 clients in adapted program with 140 usual care patients and 140 intervention patients in the IMPACT study (Grypma et al, 2006) Dissemination - Implemented core components of program in 10 regional medical centers 31 KPSC San Diego After IMPACT Fewer care manager contacts

IMPACT Study Post-Study 18.9 7.9 10.2 8.7 5.1 Total contacts Clinic visits 2.8 Phone calls 32 Grypma et al, General Hospital Psychiatry, 2006. IMPACT Remains Effective >= 50 % drop in PHQ-9 depression scores

66% 68% 64% At 3 months 68% At 6 months IMPACT Post-Study 33 Grypma et al, General Hospital Psychiatry, 2006. Lower Total Health Care Costs $8,800 $8,400

$ / year Study Usual Care $8,000 Study IMPACT $7,949 $7,600 $7,200 $7,471 Post Study IMPACT $6,800 34 Grypma, et al; General Hospital Psychiatry, 2006

Institute for Urban Family Health Number Age at enrollment: Percent Mean Range 71.6 years 60 99 years Female Male 165 74 69.0% 31.0% 90 70 56

23 37.7% 29.3% 23.4% 9.6% 44 48 47.8% 52.2% Gender: Ethnicity: Hispanic African American Caucasian Other Marital Status: Married Single, Widowed, Divorced/separated

35 IMPACT Effective for Depression Mean PHQ-9 Depression Scores 20 18 Mean Depression Scores 16 14 14.03 12 10 8.14 7.91 8 6 4

2 Initial 3 Months 6 months 0 Time 36 Change in Depression Initial to 6 months Initial PHQ-9 Depression Scores 6 Month PHQ-9 Depression Scores (Mean Score of 7.91) 160 160 63%

140 120 100 80 60 28% 40 20 0 9% Under 10: 10-14: 15-19: Mild Moderate Mod. Severe PHQ-9 Score 20+: Severe

Number of Patients Number of Patients 140 120 100 80 60 65% 40 20 0 24% Under 10: 10-14: Mild Moderate 5% 15-19: Mod.

Severe 6% 20+: Severe PHQ-9 Sore 37 A word from providers It is good to see that mental health is once again becoming part of the medical Interview, as so much of our patient's health depends on their mental well being. - Dr. Eric Gayle Project IMPACT has allowed me to incorporate a new tool (PHQ-9)into my primary care practice, which has improved the accuracy of my diagnosis while increasing my efficiency and productivity as well. It helped me identify patients I initially overlooked. -Dr. Joseph Lurio (68th Street) 38

Depression Is Associated With a Higher > 3 Cardiac Risk Factors (%) Number of Cardiac Risk Factors 100 90 80 70 60 50 40 30 20 10 0 Non Depressed Depressed 62.5 38.4

61.3 35 Diabetic Patients With CVD Diabetic Patients Without CVD N=3010 N=1215 Katon et al, J Gen Intern Med, 2004 Depression Increases Mortality Rate in Patients With Diabetes by 2-Fold Katon Katonetetal. al.Diabetes DiabetesCare, Care,2005 2005 Depression and Diabetes: More Depression Free Days over 2 Years 500 300 200

100 0 359 Increment Days 400 331 215.5 Increment 412 115.5 53 Pathways IMPACT

Intervention Usual Care Increment Two Collaborative Care Trials Demonstrate Improved Depression Care in Diabetes Lowers Total Health Care Costs Over 2 Years $22,258 $21,148 $20,000 Savings $1,110 Intervention Savings Usual Care $5,000

Intervention $18,035 $15,000 $10,000 $18,932 Usual Care $25,000 $897 $0 Pathways IMPACT Katon et al. Diabetes Care 2006, Simon et al Arch Gen Psychiatry 2007 Project Dulce + IMPACT Principal Investigator: Todd Gilmer, UCSD

Combined diabetes and depression care management program targeting low-income and primarily Spanish speaking Latinos in San Diego community clinics Added a depression care manager to an existing diabetes team (RN/CDE, promotoras) Translation for Cultural Competency DCM bilingual with experience serving Latino pop. PST-PC adapted to low-literacy population 43 Project Dulce + IMPACT Results Screened 499 patients with PHQ9 31% with scores of 10+ 75% Latino, 70% Spanish speaking 65% had depressive symptoms for 2+ years 26% interested in pharmacological treatment 74% interested in psychological treatment 48% reported financial stressors 44

Depressive Symptoms at Baseline and SixMonth Follow-Up As Measure with PHQ-9 . Inter-Quartile Range (box) Highest and Lowest (whiskers) Outlier (dots) Median 45 Gilmer et al. Diabetes Care 2008 Collaborative Care for Alzheimers Disease Collaborative Care for Alzheimers Disease Christopher M. Callahan, MD Cornelius and Yvonne Pettinga Professor Director, Indiana University Center for Aging Research Research Scientist, Regenstrief Institute, Inc. Patient NPI Score Improvement in Dementia-related Problem Behaviors

20 15 10 5 0 baseline 6months 12months Augmented Usual Care IU Center for Aging Research 18months Intervention Callahan et al. JAMA 2006

Improvement in Caregiver Stress Caregiver NPI Score 10 5 0 baseline 6months 12months Augmented Usual Care IU Center for Aging Research 18months Intervention Callahan et al. JAMA 2006

Implementing Collaborative Care Shared vision How will we know success? Shared, measurable outcomes (e.g., # and % of population screened, treated, improved) Engaged leaders & stakeholders Clinic leaders & administration PCPs, care managers, psychiatry, other mental health providers Clinical & operational integration Functioning teams, communication, and handoffs Clear about shared workflow & roles of various team members Adequate resources Personnel, IT support, funding Proactive problem solving re barriers & competing demands Minimize complexity, PDCA 49


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