Care Partners Primary Care Provider Lunch & Learn: Why PCPs Love Collaborative Care Presenter: Wayne Bentham, MD The advantage of the collaborative care model of depression management in primary care is leveraging the skills of a well trained depression care manager, with the clinical expertise of a PCP, to coordinate care, follow outcomes, and make sure patients are responding to treatment. 2 Objectives By the end of the session, participants will be able to: Understand the rationale for treating depression in primary care using a team approach Talk to patients about depression and Collaborative Care in the context of a 15 minute appointment Communicate and collaborate within the care team GLOBAL BURDEN OF DISEASE: WORLD HEALTH ORGANIZATION 1990 2020 1 Lower respiratory infection 2 Conditions arising during the perinatal period 3 Diarrheal diseases 4 Unipolar major depression 5 Ischemic heart disease 6 Vaccine-preventable disease 1 Unipolar major depression 2 Ischemic heart disease 3 Road traffic accidents 4 Cerebro-vascular disease 5 Chronic obstructive pulmonary disease 6 Lower respiratory infections 3 Murray & Lopez, WHO: Global Burden of Disease, 1996; Michaud, JAMA, 2001 4 Making a Diagnosis Symptoms Under Recognition/ Undertreatment Only 29% of persons with depression reported contacting a mental health professional in the past year* Functional Impairment Disorder 30% 70% of depression missed by PCPs 50% stop medication within 3 months 50% of treated patients in primary care remain depressed after 1 year *NHANES, 2005-6 6 1
Why PCPs Love Collaborative Care 10/19/2016 Depression is Associated with... Cycle of Depression Smoking Overweight Poor Glycemic Control Decreased Medication Adherence Increased hospitalizations Increased Costs Suicide 7 How many of these people with mental health concerns will see a mental health provider? No Treatment Primary Care Provider A PCP from Family Health Centers of San Diego posed the following scenario: A patient comes into my exam room complaining of hip pain, even though the appointment was supposed to be about her diabetes. On top of that, I reviewed the PHQͲ9 she just filled out and her score is 18. How am I supposed to prioritize my limited time with this patient? How would I fit a review of the PHQͲ9, a discussion about depression, and a warm handoff/connection into this appointment? Mental Health Provider Wang P, et al., Twelve-Month Use of Mental Health Services in the United States, Arch Gen Psychiatry, 62, June 2005 10 Other questions you may have: What exactly is collaborative care for depression? Why am I being asked to do this? Who is this depression care manager that I keep hearing about? Why can t I use the psychiatrist I have? Why can t we hire another psychiatrist? The Evidence 11 12 2
Usual Care PCP Introducing the Collaborative Care Model & Team PCP Core Program Patient Patient Care Manager Psychiatric Consultant Psychotherapist Additional Clinic Resources 13 PCP oversees all aspects of patient s care. Introduces collaborative care team Diagnoses common mental disorders Starts & prescribes pharmacotherapy Makes treatment adjustment in consultation with team 14 Twice as Many People Improve Percent (%) Improvement 50 % or greater improvement in depression at 12 months 70 Usual Care IMPACT 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 Participating Organizations Unützer et al., JAMA 2002; Psych Clinics North America 2004 US Preventive Services Task Force Recommendation Screening adults for depression when staff assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow up. Grade: B recommendation 16 Introducing the Collaborative Care Model & Team The Care Model PCP Core Program Patient Care Manager Psychiatric Consultant Psychotherapist Additional Clinic Resources 17 PCP oversees all aspects of patient s care. Introduces collaborative care team Diagnoses common mental disorders Starts & prescribes pharmacotherapy Makes treatment adjustment in consultation with team 18 3
What do the care managers do? Take an in depth mental health history Provide psycho education Provide brief, evidence based interventions like Problem Solving Treatment and Behavioral Activation Medication adherence monitoring Follow up with patients Do relapse prevention planning Care Manager Tasks Facilitates patient engagement and education Works closely with PCP to manage caseload of all patients engaged in active treatment Performs systematic initial and follow up contacts Assists PCP and Psych Consultant with clinical assessment and differential diagnosis (Therapist) Systematically tracks treatment response Cues team to change treatment when indicated 19 Care Manager Tasks Supports medication management by PCP Provides brief, structured evidence based therapy (Therapist) Reviews challenging patients with the psychiatric consultant weekly Facilitates referral to other services as needed and available Internal and/or external referral Completes relapse prevention with patient Role for Care Manager in Medication Treatment Opportunity Time Different relationship Skills Engaging Assessing / collecting information Supporting The advantage of the collaborative care model of depression management in primary care is leveraging the skills of a well trained depression care manager, with the clinical expertise of a PCP, to coordinate care, follow outcomes, and make sure patients are responding to treatment. Comparison of Contacts in Usual Care vs. IMPACT 0 USUAL CARE 3.5 PCP Contacts per year 20% 40% treatment response/improvement 12 months 23 Based on HRSA report of average PCP visit rates for FQHCs 4
Why PCPs Love Collaborative Care 10/19/2016 Comparison of Contacts in Usual Care vs. IMPACT FollowͲUp Contacts Weekly or every other week during acute treatment phase In person or by telephone to evaluate symptom severity (PHQͲ9, GADͲ7) and treatment response 0 Collaborative Care Initial focus on Adherence to medications Side effects FollowͲup on activation and PST plans 12 months 3.5 PCP Contacts per year 10 contacts with CM (on average) 2 case consultations from psychiatric consultant to CM/PCP (on average) Later focus on Complete resolution of symptoms and restoration of functioning LongͲterm treatment adherence 50% - 70% treatment response/improvement Common Measures The PHQ9 is like the A1C of Depression Depression: PHQͲ9 Diabetes A1C Depression PHQ9 28 Warm Connections (HandͲoffs): personal introductions emphasize team based care. Engaging Patients in the Model in 15 minutes The Provider s Role Please let me introduce our care manager Mary. We work as a team to help you manage your mood Reviewing the PHQͲ9 Introducing Collaborative Care to the patient Warm Handoffs/Connections FollowͲup of onͳgoing care 29 30 5
Model Introduction We provide mental health care as a team at this clinic. You will be cared for by a team. PCP will still be your medical provider A care manager to help improve your day to day function A psychiatric consultant works behind the scenes to make sure we offer you the best treatment options possible Other team members We communicate about your care. When you are working with one team member you are working with whole team. I want to set up an appointment for you to meet her/him OR introduce you to her/him right now. If you have any concerns or doubts about the program, call me to discuss them. Cycle of Depression 31 Typical Duration of Care Management 6 Months (average) Best if determined by clinical outcomes, not preset 50% 70% of patients need at least one change in treatment to improve Only 30% 50% patients respond fully to 1st treatment Each change of Tx moves an additional ~20% of patients into response or remission A PCP from Family Health Centers of San Diego posed the following scenario: A patient comes into my exam room complaining of hip pain, even though the appointment was supposed to be about her diabetes. On top of that, I reviewed the PHQ 9 she just filled out and her score is 18. How am I supposed to prioritize my limited time with this patient? How would I fit a review of the PHQ 9, a discussion about depression, and a warm handoff/connection into this appointment? 34 So, to summarize: Screen patients for depression Make discussion of screening results a priority Have a plan for introducing your care manager to your patient Your care manager is your friend!! Have a plan for your care manager to follow up with you Schedule follow up appointments to specifically address depression treatment 35 Principles Patient Centered Collaboration. Primary care and mental health providers collaborate effectively using shared care plans. Population Based Care. A defined group of clients is tracked in a registry so that no one falls through the cracks. Treatment to Target. Progress is measured regularly and treatments are actively changed until clinical goals are achieved. Evidence Based Care. Providers use treatments that have research evidence for effectiveness. Accountable Care. Providers are accountable and reimbursed for quality of care and clinical outcomes, not just volume of care. 6
Why PCPs Love Collaborative Care 10/19/2016 Opportunities!! 37 Questions? Discussion Thoughts? Ideas? What else would be helpful for you? 39 40 7