Denver Health s Roadmap to Reduce Racial Disparities: Telephonic Counseling for Depression and Anxiety David Brody, MD Medical Director Denver Health Managed Care Plans Professor of Medicine University of Colorado School of Medicine
Denver Health and Hospital Authority
Recognition of Problem
Observed adherence to indicators of quality of depression care Quality indicator Observed Adherence PCP detection of depression 79% Follow-up for patients newly started in antidepressant therapy 80% Completion of initial treatment 46% Treatment adjustment for non responsive patients 36% Hepner K. et al Ann. of General Int. Med. 2007 4
Observed Adherence to indicators of quality of Depression care Quality indicator Observed Adherence PCP assessment of symptoms and depression history 34% PCP suicide assessment 24% PCP alcohol assessment 23% PCP referral to mental health specialist for suicidal ideation PCP referral to mental health specialist for patients still depressed at 6 months 36% 30% Hepner K et al Ann of Internal Med 5 2007
PCP Management of Depression The Good - Detection of depression - Follow-up of newly treated patients The Bad - Adherence to antidepressant medications The Ugly - Treatment adjustment for non responders - Assessment of symptoms, past history and comorbidity - Referral to specialists - Use of evidence based psychotherapy 6
These problems are worse for care provided to low income minority patients: - Ethnic minorities less likely to obtain mental health care than whites - Those who obtain mental health care from PCPs are less likely to receive appropriate care or be referred to mental health specialists 7
Quality Improvement Structure at Denver Health
Mental Health Work Group PCPs Family Medicine General Internal Medicine Psychologists Psychiatrist Pharmacist
Project Goals 1. Complete a comprehensive diagnostic assessment 2. Improve adherence to antidepressant medication 3. Facilitate adjustment of medication based on outcomes 4. Provide brief evidence based therapy 5. Improve depression outcomes
Design the Intervention: Root Cause Analysis Levels of Influence Providers Barriers Time Training Patients Stigma Transportation Competing demands Language Cost System/Community Policy Access Reimbursement
The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta- Analysis Twelve trials of telephone-administered psychotherapies, in which depressive symptoms were assessed, were included. These findings suggest that telephoneadministered psychotherapy can produce significant reductions in depressive symptoms. Attrition rates were considerably lower than rates reported in face-to-face psychotherapy. Mohr DC et al Clin Psch: Science and Practice:15N3, 9-2008
Engaging Providers Clinic meetings Email Feedback reports
Engaging Patients Posters Brochures Recruitment letter from PCP Program offered evenings and weekends Counseling provided in English and Spanish Pictures of therapists Post call visit summaries Telephone reduces: Need for transportation and child care Stigma Cost Barriers to dissemination
Overcoming System, Community and Policy Barriers Barrier Solution Access to mental health specialists Short-term evidence based telephonic counseling Reimbursement Grant funding Negotiating reimbursement with BHC Broaden payor mix
Outcomes monitoring calls at baseline, 6, 12 & 24 weeks
Program Evaluation Randomized clinical trial Patient satisfaction Provider survey Provider interviews
Key Findings 1. Intervention resulted in improved outcomes 2. Equally effective in English and Spanish speakers 3. Patients who participated in more calls had better outcomes 4. Patients who were referred by PCP had better outcomes 5. High drop out rate 6. Behavioral activation doesn t work for everyone
Program Changes 1. Recruitment only by provider or self referral 2. Increased number of therapy sessions to 8 3. Improved provider feedback process 4. Expanded the types of therapy we provide
Second Iteration Enhanced with Module Choices Patients can chose at least 3 call topics Getting Going Grief and Loss Healthy Eating Healthy Relationships Improve Sleep Patterns Manage Stress Better Mind Tricks for Pain Overcoming Illness Physical Activity Positive Thinking Problem-Solving Worrying Less Next up-trauma
Third Iteration Enhanced with Technology and Integrated Tools Partnership with mystrength allows us to coordinate the telephonic counseling modules with between visit online support Automated Between Visit Outreach Homework reporting Symptom tracking Motivational messaging Helpful tips Patient stories Automated Post Program Outreach PHQ9, GAD7 with programmed responses based on results Motivational messaging Helpful tips Connection to community resources and ongoing support