Published Online: December 01, 2007
Chuan-Fen Liu, PhD; John Fortney, PhD; Susan Vivell, PhD; Karen Vollen, MA; William N. Raney, MA; Barbara Revay, BS; Maurilio Garcia-Maldonado, MD; Jeffrey Pyne, MD; Lisa V. Rubenstein, MD, MPH; and Edmund Chaney, PhD
Objective: To document time allocated to care management activities and care manager workload capacity using data collected for studies of telephone care management of depression.
Study Design: Cross-sectional, descriptive analysis of depression care manager (DCM) activities and workload in 2 collaborative depression care interventions (1 implementation study and 1 effectiveness study) at Department of Veterans Affairs primary care facilities.
Methods: Each intervention tracked specific care management activities for 4 weeks, recording the number of events for each activity type and length of time for each activity. Patient workload data were obtained from the patient tracking systems for the 2 projects. We calculated the average time for each activity type, the average total time required to complete an initial assessment call and follow-up call, and the maximum patient panel for both projects.
Results: The total time per successful initial assessment was 75 to 95 minutes, and the total time per successful follow-up call was 51 to 60 minutes, with more time spent on ancillary activities (precall preparation, postcall documentation, and provider communication) than on direct patient contact. A significant amount of time was spent in unsuccessful call attempts, requiring 9 to 11 minutes for each attempt. The maximum panel size per care manager per quarter was in the range of 143 to 165 patients.
Conclusions: The study found similar DCM time allocations and panel sizes across 2 studies and 3 regions with full-time DCMs. Reductions in DCM time spent on ancillary activities may be achievable through improved informatics and other support for panel management.
(Am J Manag Care. 2007;13:652-660)
Telephone care management is shown to significantly improve depression treatment outcomes in primary care, but there is little information on resources required for telephone care management of depression. This paper documents that:
Two telephone care management projects had similar care manager time allocations and panel sizes.
The total time per successful initial assessment was 75 to 95 minutes, and the total time per successful follow-up call was 51 to 60 minutes, with more time on ancillary activities (precall preparation, postcall documentation, and provider communication) than on direct patient contact.
The maximum panel size per care manager per quarter was 143 to 165 patients.
Collaborative care is a population-based approach to treating depression in which multidisciplinary care teams assist primary care providers (PCPs) in delivering evidence-based treatment. The collaborative depression care model, based on a chronic illness care management model, includes patient-, provider-, and system-level components.1,2
A recent review of collaborative-care trials demonstrated this approach to be successful in improving both the process and outcomes of depression care.3
Using care management to systematically monitor adherence to treatment and follow-up care is a key element in collaborative care.4
Inclusion of systematic follow-up is an important predictor of positive clinical outcomes for depression.5
The care manager provides structured assessment and monitoring, education, and self-management support in partnership with the depression care team. The care manager role is based on the â€śclinical case managerâ€ envisioned by Kanter6
more than the typical coordination and service support role of a case manager.
Among collaborative-care models, several types of medical professionals (nurses,7,8
) or nonmedical professionals with healthcare experience13
have taken the role of care manager. Care management is conducted through on-site visits,9
or a combination of both.17,18
Care management by telephone, a less expensive approach than in-person patient visits, can significantly improve treatment of depression in primary care settings.14,19,20
Information about the resources required for telephone care management is important for administrators and policymakers planning to implement collaborative-care models. However, no research has prospectively documented the time allocated to care management activities or estimated the workload capacity of depression care managers (DCMs). Based on data collected for 2 studies of telephone care management of depression, we describe the time care managers devote to specific clinic activities and provide estimates of care manager workload in terms of maximum patient panel sizes. The 2 programs were implemented in multiple primary care clinics in the Department of Veterans Affairs (VA) healthcare system. By documenting care management activities and resource needs, we hope within and outside the VA with concrete information for planning collaborative-care interventions to improve depression treatment.METHODS Study Design
This study is a cross-sectional, descriptive analysis of DCM activities and workload in 2 collaborative depression care interventions implemented in different VA primary care facilities. The Translating Best Practices for Depression into Evidence-based Solutions (TIDES) project was an implementation study conducted in 7 outpatient clinics in rural areas or small cities with on-site mental health staff in 3 VA regional healthcare networks, with 1 nurse DCM in each network. The TIDES clinics had 4600 to 14 000 primary care patients per year and 4 to 10 primary care clinicians. The Telemedicine Enhanced Antidepressant Management (TEAM) study was an effectiveness study conducted in 3 small community-based outpatient clinics without on-site psychiatrists in 1 regional healthcare network with 1 nurse DCM. The TEAM clinics had from 2900 to 4800 primary care patients per year and 5 to 10 primary care clinicians.
Both TIDES and TEAM DCMs were primary care registered nurses. Although the implementation plan for both projects did not require DCMs to have mental health experience, 2 of 3 TIDES DCMs (one with a master's degree and one with a bachelor's degree) and the TEAM DCM (who had a master's degree) were senior nurses with considerable experience in mental health. The third TIDES DCM, who had a 2-year associate's degree, had no experience in mental health and, in addition to psychiatric supervision, was mentored by the 2 other TIDES DCMs. The TIDES DCMs received an initial 2-day training session in depression care management and TIDES protocols before accepting patients. The TIDES DCMs also participated in weekly conference calls for support, problem solving, and care management education. The training for the TEAM DCM included directed readings and role playing over a 3-month period before patient enrollment. Both TIDES and TEAM DCMs worked full-time on the projects and were not involved in other clinical duties or research projects.Table 1
presents characteristics of the TIDES and TEAMS interventions.Translating Best Practices for Depression into Evidence-based Solutions
TIDES implemented a model of collaborative care based in primary care with mental health collaboration. The implementation strategy was the evidence-based quality improvement process, a structured implementation model that begins with establishing a work agreement between researchers as facilitators and regional and local administrators with organizational and fiscal decision-making authority. Implementation structure, templates, and protocols for the collaborative-care model are locally developed based on organizational priorities and resources, with guidance from the research/facilitation team. The implementation includes continuing education for PCPs and mental health specialists; information technology staff are involved, and to the extent practical, the electronic medical record is optimized for collaborative care.
In the TIDES depression care management model, PCPs referred patients with depressive symptoms to the DCM for assessment and follow-up care. DCMs followed a locally designed protocol for initial assessment of depression symptoms using a modified version of the 9-item Patient Health Questionnaire (PHQ-9) approved by Kroenke et al.21
The modified version of PHQ-9 asked the second question (which referred to â€śfeeling down, depressed or hopelessâ€ť) first. Also, the modified version used a â€ś2 passâ€ method, first asking about the presence of each symptom and then asking about the frequency of endorsed symptoms. Follow-up scores on the PHQ-9 were used to track patient progress over time. Patient treatment preferences were respected, with some patients receiving antidepressant medications, some on a â€śwatch & waitâ€ status, and some referred for psychotherapy. Patients were followed for 6 months by the DCM with at least 4 calls scheduled at 1-2 weeks, 4-6 weeks, 8-12 weeks, and 24 weeks. Frequency of calls was tailored to patient progress. During each call, the DCM asked for the best way to reach a patient, including cell phone number, but did not schedule the next call routinely. Patients who were referred to mental health were monitored for compliance in keeping their mental health appointments and had the PHQ-9 repeated at 6 months by the DCM.
DCMs tracked patients' response to medications; provided follow-up care primarily in the form of social support and education about symptoms, therapy, recovery strategies, and specific strategies in self-management (eg, goal setting, formulating questions to ask PCPs, accessing information and resources for depression treatment); and addressed problems and barriers that arose. However, the DCMs did not provide psychotherapy. Centrally located (at the regional level) DCMs contacted patients by telephone, which was preferred by many patients and also allowed the DCMs to work with patients in remote settings. Formative evaluation showed that TIDES was a successful model of stepped care in which, among patients referred to DCMs, 82% were treated for depression in primary care, 74% stayed on medication, and 90% of primary care patients and 50% of mental health patients had clinically significant reduction in depressive symptomatology (PHQ-9 scores <10) at 6 months.22-24Telemedicine Enhanced Antidepressant Management
The purpose of the TEAM effectiveness study was to adapt the collaborative-care model for small primary care clinics without on-site psychiatrists, using telemedicine technologies without altering the nature/content of the collaborative-care model itself.19
Telemedicine (eg, telephone, interactive video, electronic medical records, Internet) facilitated communication between a centrally located depression care team and PCPs practicing in geographically diverse clinic locations. The TEAM intervention used a stepped-care intervention, beginning with a standard level of care for all patients and increasing treatment intensity for patients failing to respond to lower levels of care. Patients and providers chose either watchful waiting or treatment with an antidepressant medication, although providers were encouraged via the positive depression screen in the electronic medical record to initiate guideline-concordant antidepressant treatment. Each additional level of stepped care involved a greater number of intervention personnel with increasing mental health expertise. Patients received the intervention for a 12-month acute-treatment phase or until a 6-month continuation phase was complete (without a relapse), whichever came first. Intervention participants included (1) PCPs located at community-based outpatient clinics; (2) consult telepsychiatrists located at parent VA medical centers; (3) an off-site DCM; (4) an off-site clinical pharmacist (with a PharmD degree); and (5) an offsite supervising psychiatrist. The supervising psychiatrist provided clinical supervision to the DCM and clinical pharmacist via weekly face-to-face meetings.
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