Strategies for Identifying and Channeling Patients for Depression Care Management

This article examines screening strategies for possible depression in the context of a care management program for chronically ill Medicare recipients.
Published Online: August 01, 2008
Jennifer K. Taylor, PhD; Michael Schoenbaum, PhD; Wayne J. Katon, MD; Harold A. Pincus, MD; Diane M. Hogan, RN, MA; and J??rgen Un??tzer, MD, MPH

Objective: To determine optimal methods of identifying enrollees with possible depression for additional depression screening in the context of a care management program for chronically ill Medicare recipients.

Study Design: Observational analysis of telephone and mail survey and claims data collected for the Medicare Health Support (MHS) program.

Methods: This study examines data from 14,902 participants with diabetes mellitus and/or congestive heart failure in the MHS program administered by Green Ribbon Health, LLC. Depression screening was performed by administering a 2-item screen (the Patient Health Questionnaire 2 [PHQ-2]) by telephone or by mail. Additional information about possible depression was drawn from International Classification of Diseases, Ninth Revision (ICD-9) depression diagnoses on claims and from self-reported use of antidepressant medications. We evaluated positive depression screens using the PHQ-2 administered via telephone versus mail, examined variations in screener-positive findings by care manager, and compared rates of positive screens with antidepressant use and with claims diagnoses of depression.

Results: Almost 14% of participants received an ICD-9 diagnosis of depression during the year before program enrollment; 7.1% reported taking antidepressants, and 5.1% screened positive for depression on the PHQ-2. We found substantial variation in positive depression screens by care manager that could not be explained by case mix, prior depression diagnoses, or current depression treatment. After adjusting for demographic and clinical differences, the PHQ-2–positive screen rates were 6.5% by telephone and 14.1% by mail (P <.001).

Conclusion: A multipronged effort composed of mail screening (using the PHQ-2), self-reported antidepressant use, and claims diagnoses of depression may capture the greatest number of enrollees with possible depression.

(Am J Manag Care. 2008;14(8):497-504)

This article examines screening strategies for possible depression in the context of a care management program for chronically ill Medicare recipients.

A combined telephone depression screening approach with mail screening (using the Patient Health Questionnaire 2), augmented by information about antidepressant use and by claims diagnoses of depression, may identify enrollees with possible depression.

Telephone screenings for depression may vary by screener based on screener characteristics. Specific training for screeners of depression may reduce this variability.

Chronic conditions are leading causes of illness, disability, and death among Medicare beneficiaries and account for a disproportionate share of healthcare expenditures. About 14% of Medicare beneficiaries have heart failure (accounting for 43% of Medicare spending), while approximately 18% of Medicare beneficiaries have diabetes mellitus (DM) (accounting for 32% of Medicare spending).1 The Medicare Modernization Act of 2003 (§721) created the voluntary Medicare Health Support (MHS) program to coordinate care for high-risk Medicare beneficiaries with chronic illness under traditional fee-for-service Medicare.2 In its initial phase, the MHS program consisted of 3-year pilot programs at 8 sites across the United States, each operated by a different MHS organization. The MHS program provides care management services to Medicare beneficiaries with congestive heart failure (CHF) or complex DM. Each site represented a randomized controlled trial and/or covered 20,000 to 30,000 participants. Enrollment began in the summer of 2005.

Phase 1 of the MHS program recommends screening for depression. Patients with DM and CHF have a 2-fold higher prevalence of depression than other medical control subjects.3 Based on the severity and complexity of their condition, the MHS target population is likely to have prevalence rates of major depression ranging from 15% to 25%. Medically ill patients with comorbid depression have lower adherence to recommended treatments and to self-care regimens, such as diet changes and increased exercise.4 Medically ill patients with comorbid depression are more functionally impaired, manifest increased complication and mortality rates, and have 50% to 100% higher medical costs than those without depression, even after controlling for demographics and severity of medical illness.5 Improving the quality of depression management for patients with comorbid depression and DM has been shown to improve patients’ depression outcomes and to decrease medical costs during a 2-year period relative to “usual” care.6,7

This article describes efforts to optimize the identification of program participants with possible depression by the Green Ribbon Health, LLC (GRH) MHS organization. We used various methods to identify participants who should be further evaluated for the presence of depression by care managers (CMs) using the Patient Health Questionnaire 2 (PHQ-2) and, if needed, should be provided with additional resources for depression management. Although a growing consensus exists about the value of identifying depression as a necessary first step to effective intervention, there is little evidence about practical methods for large-scale depression screening, particularly in a real-world population of medically ill older adults. We discuss training and tactics to enhance telephonic depression screening. We also report discrepancies in depression prevalence among different methods of administering the PHQ-2 (ie, telephonic, by mail, or in person). Finally, we discuss the potential benefits of combining administrative and screener data into a multipronged hierarchical depression screening strategy.

This study examines depression screening data from 14,902 Medicare beneficiaries participating in the GRH MHS program who completed an initial Medicare Domain Assessment tool (hereafter, mDAT1). The MHS program is designed to serve fee-for-service Medicare beneficiaries with CHF and/or complex DM who live in MHS catchment areas ( Programs. asp).2 Beneficiaries were ineligible for the MHS program if they belonged to a Medicare Advantage plan, had end-stage renal disease, or were enrolled in hospice care. Green Ribbon Health, LLC serves MHS beneficiaries in 9 counties in Florida. The program commenced on November 1, 2005.

The core of the GRH multidisciplinary care coordination model is telephonic interface by a personal nurse, who educates and supports participants in managing their health and in following their providers’ prescribed plan of care. If a personal nurse believes that a participant’s condition warrants a more intensive face-to-face intervention, the participant is contacted by a member of the field CM team. This team is composed of social workers and registered nurses who coordinate or provide appropriate services.

All participants receive a health assessment at least every 6 to 12 months using the mDAT developed for GRH. Depression screening is a core requirement of the program by GRH and is administered at set intervals as part of the mDAT. The mDAT includes the PHQ-2, which is a 2-item depression screener.8 All GRH participants with possible depression are eligible to receive health support and education regarding depression (eg, prevalence, risks, and treatment options). Participants screening positive for depression on the PHQ-2 are further evaluated using the PHQ-9.9 They may then be referred to their primary care provider or to a specialist for assessment, diagnosis, and treatment recommendations. The CM team monitors depressive symptoms and response to treatment and provides information to participants to help them manage their symptoms and connect with appropriate resources. Care managers also promote self-care and help participants communicate directly with their physicians. For participants whose depression is not improving, CMs interface with the provider for review and adjustment of the treatment plan.

Data and Measures
Data on GRH MHS participants come from 3 main sources. These include (1) mDATs administered by GRH, (2) selfreported use of prescription drugs as assessed by interviews with GRH CMs (typically along with mDATs), and (3) Medicare eligibility and claims data provided by the Centers for Medicare & Medicaid Services (CMS).

Demographics. Limited demographic information was available from the CMS, including participants’ age, sex, and race/ethnicity. Other sociodemographic measures, particularly education, literacy, and occupation, were available for fewer than 5% of participants.

Clinical Status and Case Mix. The CMS data included the conditions for which participants qualified for the MHS program (ie, DM, CHF, or both), participants’ Hierarchical Condition Category (HCC) risk score (ie, the CMS version of the HCC risk-adjustment method), and high-, medium-, or low-risk designations based on the HCC score. In addition, GRH developed a risk-tiering algorithm that uses the HCC score and the mDAT to classify participants into categories of intervention need. These measures were later used to balance CM caseloads to assess any differences among positive depression screens.

Depression Status. Possible depression status came from 3 sources. These included (1) the PHQ-2 screens via the mDAT (a score of ≥3 of 6 is the optimum cutoff point on the PHQ-2)8; (2) the International Classification of Diseases, Ninth Revision (ICD-9) depression diagnosis codes from Medicare claims data with service dates between November 2004 and March 2007 (codes 296.2, 296.3, 298.0, 300.4, 309.1, and 311 for current depression and codes 296.2-296.9, 298, 300.4, 309.0, 309.1, 309.28, and 311 for prior episodes of depression); and (3) self-reports of lifetime antidepressant medication use (medications with US Food and Drug Administration indications for depression) from the GRH medication assessment interviews collected by CMs between November 2005 and May 2007.

To assess the rate of possible depression, we examined the proportion of participants who screened positive on the PHQ-2 mDAT1, the proportion with a diagnosis of depression during the past year, and the proportion reporting antidepressant use. In addition, because CMs varied in their experience with depression, we examined whether this affected their administration of the PHQ-2. To assess possible variation, we evaluated whether positive PHQ-2 screening rates varied by CM after adjusting for differences in caseload composition. We anticipated the use of focus groups among CMs in the event of significant variation in positive depression screens. This would allow us to determine the source of such variation and to provide training to minimize future discrepancies.

Almost all (98.7%) mDAT1s were administered by telephone; 13.8% of completed follow-up assessments (mDAT2s) were administered by mail. Green Ribbon Health, LLC conducted a “mail blitz” campaign to raise mDAT response rates and to follow up on participants who were difficult to reach by telephone. Overall, 85.1% of participants (n = 12,677) who completed the mDAT1 completed the mDAT2. We examined differences in PHQ-2–positive rates between telephone- and mail-based mDATs using bivariate analysis and multivariate logistic regression analysis to account for possible differences in caseloads.

Finally, we examined the efficiency of alternative depression screening strategies among the sample. Particularly, we illustrate the degree of independence and overlap between the following 3 sources of information on possible depression: PHQ-2 screens, self-reported use of antidepressants, and ICD-9 depression diagnoses.

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